Barriers to Universal Prescribing of Antiretroviral Therapy by HIV Care Providers in the United States, 2013-2014

Introduction: HIV treatment guidelines recommend initiating ART regardless of CD4 cell (CD4) count, barring contraindications or barriers to treatment. An estimated 6% of persons receiving HIV care in 2013 were not prescribed antiretroviral therapy (ART). We examined reasons for this gap in the care continuum. Methods: During 2013-2014, we surveyed a probability sample of HIV care providers, of whom 1,234 returned surveys (64.0% adjusted response rate). We estimated percentages of providers who followed guidelines and their characteristics, and who deferred ART prescribing for any reason.
Results: Barring contraindications, 71.2% of providers initiated ART regardless of CD4 count. Providers less likely to initiate had caseloads 200 patients (adjusted prevalence ratios [aPR] 0.69, 95% confidence interval [CI] 0.47-1.02, P=.03), practiced at non-Ryan White HIV/AIDS Program (RWHAP)-funded facilities (aPR 0.85, 95% CI 0.74-0.98, P=.02), or reported pharmaceutical assistance programs provided insufficient medication to meet patients' needs (aPR 0.79, 95% CI 0.65-0.98, P=.02). In all, 17.0% never deferred prescribing ART, 69.6% deferred for 1-10% of patients, and 13.3% deferred for >10%. Among providers who had deferred ART, 59.4% cited patient refusal as a reason in >50% of cases; 31.1% reported adherence concerns due to mental health disorders or substance abuse and 21.4% reported adherence concerns due to social problems, e.g., homelessness, as factors in >50% of cases when deferring ART.
Conclusions: An estimated 29% of HIV care providers had not adopted recommendations to initiate ART regardless of CD4 count, barring contraindications or barriers to treatment. Low-volume providers and those at non-RWHAP-funded facilities were less likely to follow this guideline. Among all providers, leading reasons for deferring ART included patient refusal and adherence concerns.