Delayed uptake of ART in Australia
A review of HIV surveillance, clinical cohort and social research data suggests that many people living with HIV (PLHIV) in Australia delay, cease or do not take up HIV antriretroviral therapy (ART) due to structural and psychological barriers.
CD4 loss between HIV diagnosis and ART initiation
Since 2006, the median CD4+ cell count at HIV diagnosis among PLHIV has been 399 cells/µl or higher.1
Data from the Australian HIV Observational Database for the same period shows that the median CD4+ cell count at treatment initiation was just 294 cells/µl. 2
“These data suggest that for many PLHIV who do commence ART, there is a significant gap between diagnosis and treatment initiation.”
Late initiation compared to recommendations in ARV guidelines
These data suggest that for many PLHIV who do commence ART, there is a significant gap between diagnosis and treatment initiation, and that for many PLHIV initiation was delayed until after their CD4 levels had fallen below the point where treatment was recommended by antiretroviral treatment guidelines. Over the period where data was reviewed, the DHHS ARV guidelines (followed in Australia) had initially recommended that ART be offered to people with a CD4 cell count between 201 and 350 cells/µl.3 and then recommended ART for people with CD4 between 350 and 500 (December 2009). 4
Barriers to HIV treatment
There are thousands of PLHIV who have not taken up or have discontinued treatment. A 2011 analysis estimated that up to 48% of Australian PLHIV were not on treatments.5 Data from behavioural surveys have reported higher proportions of PLHIV on treatment.6
Studies among PLHIV and prescribers have documented various psychological and structural barriers to treatment. The Tracking Changes Study documented psychosocial barriers such as fear of side-effects and reluctance to initiate lifelong treatment.7
Structural barriers to treatment due to restricted ARV dispensing sites8 and financial barriers due to patient co-payment costs9 have also been identified as reasons why some PLHIV cease or interrupt treatment.
“I had thought it would be difficult for me to commence meds since this would be an acknowledgment of the progression of my HIV. However, since starting my meds I have found that a lot of small irritating conditions have cleared up and my overall health is significantly improved. I'm just grateful every day that the meds exist!” (ARCSHS Tracking Changes, 2011)
‘Start the Conversation’ Campaign
In addition to the documented psychological barriers to treatment, NAPWHA’s experience suggested that many PLHIV may not be aware of new scientific understandings regarding the benefits of early initiation and/or improvements in therapy.
NAPWHA’s ‘Start the Conversation’ campaign aimed to improve treatment uptake by encouraging PLHIV to talk to their doctors about the benefits of HIV treatments for themselves and their partners. The national campaign ran in national media in June and July 2012. An independent evaluation of the campaign is currently underway.
“Many PLHIV may not be aware of new scientific understandings regarding the benefits of early initiation and/or improvements in therapy.”
Further social marketing initiatives to address psychological barriers among PLHIV and doctors to uptake of HIV treatments are needed, along with advocacy for policy changes to reduce structural barriers to HIV treatments access.
NAPWHA recommends that clinicians should initiate discussion with PLHIV regarding treatments at an earlier point, to assist in identifying psychological barriers to treatment, and the information and support needs of PLHIV in preparing for treatment.
Poster presented at the Australasian HIV/AIDS Conference, Melbourne, 2012.
PDF of poster attached below for downloading.
- The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2011. The Kirby Institute, the University of New South Wales, Sydney, NSW.
- Australian HIV Observational Database, The Kirby Institute. 2011.
- Hoy J, Lewin S, Post J, Street A (Eds.). HIV Management in Australasia: A guide for clinical care. 2009. Australasian Society for HIV Medicine, Sydney. Subsequent updates to ARV guidelines strengthened the recommendation to initiate below 350 cells/µl, and suggested ART be considered in people with CD4 above 350 (December 2007),
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. December 1, 2009; 1-161.
- The Kirby Institute. National Blood-borne Virus and Sexually transmissible Infections Surveillance and Monitoring Report, 2011. The Kirby Institute, the University of New South Wales, Sydney, NSW.
- Behavioural surveys have reported higher rates of treatments uptake; in the Gay Community Periodic Surveys (ARTB, NCHSR, 2011) and the Futures 6 Survey (ARCSHS 2009) 69.5% and 79.6% of respondents respectively reported being on ART.
- J Grierson, R Koelmeyer and M Pitts (2011) Tracking Changes: Tracking the Experiences of Starting and Switching Highly Active Antiretroviral Therapy in Australia, Monograph Series Number 85, The Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia.
- NAPWHA submission (2009). Review of the existing supply arrangements for drugs listed under Section 100 of the National Health Act 1953. NAPWHA, Sydney.
- J McAllister, G Beardsworth, E Lavie, K MacRae and A Carr. (2012) Financial stress is associated with reduced treatment adherence in HIV-infected adults in a resource-rich setting. HIV Medicine. 2012. Jul 10. doi: 10.1111/j.1468-1293.2012.01034.x. [Epub ahead of print]