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Study finds delays in prescribing protease inhibitors for some HIV-infected individuals

Protease inhibitors (PIs), in combination with other antiretroviral medications, have dramatically improved the lives of HIV-infected patients. Following current HIV treatment guidelines, physicians tend to delay prescribing antiretroviral therapy for patients they think are unlikely to take their medication regularly. There is some evidence that lack of adherence promotes drug resistance and may lead to worse health outcomes.

Most providers consider patient adherence an important factor in their decision to prescribe PIs, and this attitude apparently accounted for the relatively later use of PIs for Latinos, women, and the poor found in a recent study. The study was supported in part by the Agency for Healthcare Research and Quality (HS08578), as a followup to the HIV Cost and Services Utilization Study (HCSUS). HCSUS was led by co-principal investigators Martin F. Shapiro, M.D., Ph.D., of RAND and the University of California, Los Angeles School of Medicine, and Samuel A. Bozzette, M.D., Ph.D., of RAND and the University of California, San Diego.

The researchers analyzed HCSUS data on 1,717 HIV-infected adults eligible for PI treatment and 367 providers who cared for them. They examined the relationship between a physician's attitude toward prescribing PIs to nonadherent patients (less than 80 percent of pills taken) with disparities in PI use and health outcomes seen between 1996 and 1998. Overall, 89 percent of providers agreed that patient medication adherence was important in their decision to prescribe PIs (selective), while 11 percent disagreed (nonselective).

Patients who had a selective provider received PIs later than those who had a nonselective provider. Adjusting for patient health and other characteristics as well as provider characteristics (for example, HIV experience and specialty), Latinos, women, and poor patients received PIs later if they had a selective provider. These groups received PIs as soon as others if they had a nonselective provider. Blacks received PIs later than whites, irrespective of their provider's prescribing attitude. However, whether or not certain groups are less adherent to HIV therapy remains unclear, and physician bias may play a role, notes Mitchell D. Wong, M.D., Ph.D., the study's lead author.

See "Disparities in HIV treatment and physician attitudes about delaying protease inhibitors for nonadherent patients," by Dr. Wong, William E. Cunningham, M.D., M.P.H., Dr. Shapiro, and others, in the April 2004  Journal of General Internal Medicine 19, pp. 366-374.

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