BOSTON — Almost half of HIV-positive individuals in the United States who meet federal guidelines for antiretroviral therapy may not be receiving the treatment, according to a recent estimate by the Centers for Disease Control and Prevention.
Late diagnoses, unawareness of HIV risk factors and risk status, and treatment inaccessibility are among the likely factors contributing to the insufficient care of as many as 44% of the country's treatment-eligible HIV-positive individuals, CDC medical epidemiologist Eyasu Teshale, M.D., reported at a conference on retroviruses and opportunistic infections.
Using data from an analysis of AIDS diagnoses reported by all 50 states and HIV diagnoses reported by 30 states with well-established integrated HIV/AIDS reporting systems and lab-based CD4 reports, the CDC investigators estimated that, through 2003, there were about 480,000 treatment-eligible HIV/AIDS patients in this country.
Federal treatment guidelines recommend antiretroviral therapy for HIV-infected patients with CD4 white blood cell counts of 350 cells/μL or lower; yet according to a statistical model, only 56% of eligible patients likely received the recommended therapy, said Dr. Teshale.
To estimate the number of HIV/AIDS patients receiving antiretroviral therapy, the CDC investigators extrapolated treatment percentages from CDC's Adult/Adolescent Spectrum of HIV Disease (ASD) project, a 10-city medical records-based surveillance project that prospectively collected information from more than 60,000 HIV/AIDS patients from 1990 through June 2004.
About 79% of the HIV-infected patients in the ASD population with CD4 counts below 350 cells/μL received antiretroviral therapy. “We applied that proportion to the 340,000 patients estimated to be 'in care' on a national level,” Dr. Teshale said. Using this approach, the investigators estimated that 268,000 (79%) of the 340,000 patients diagnosed and receiving care in the U.S. received ART at the end of 2003. These 268,000 people represent only about 56% of the 480,000 Americans aged 15-49 who were living with HIV/AIDS and were eligible for ART at the end of 2003.
An estimated 42% of eligible patients not getting antiretroviral therapy have not even been diagnosed with HIV infection, and as many as 25% are likely aware of their HIV status but are not receiving medical care for it, Dr. Teshale said at the conference, sponsored by the Foundation for Retrovirology and Human Health.
Among patients who have access to health care and are being treated for HIV, barriers to receiving recommended antiretroviral treatment include the expense of the multidrug cocktails, which can cost more than $10,000 per year. Although private insurance will often cover this expense, patients receiving public health assistance are often placed on waiting lists for the drugs. Finally, some patients choose not to take the antiretroviral medications because of the side effects.
The new estimates, though limited by variations in data collection by states and inconsistencies in the medical records included in the analyses, support previous research demonstrating the unmet need for antiretroviral therapy.
The findings need to be validated by additional research, and the factors contributing to insufficient care for HIV-infected individuals deserve more study.
However, efforts to reduce the scope of the problem should be implemented without waiting for further research, Dr. Teshale said. These include increasing individuals' awareness of their HIV status, providing more methods for linking at-risk individuals to prevention and care programs, and encouraging health care providers to prescribe antiretroviral therapy, according to federal guidelines.