When do HIV-infected persons start with antiretroviral therapy? A retrospective analysis of patients' monitoring and treatment status in general practice, as compared with the 1991 Dutch HIV treatment guidelines

Objective. We aimed to compare, in a sample of Amsterdam general practices, the monitoring and treatment status of HIV-infected patients according to the 1991 Dutch consensus guidelines for antiretroviral treatment of HIV-infection, which advise that therapy be started at a peripheral blood CD4(+) cell count of less than or equal to 300 x 10(6)/l in asymptomatic patients, or less than or equal to 400 x 10(6)/l in symptomatic patients. Method. In 1994, data were collected from the records of all 511 HIV-infected patients registered in 14 Amsterdam general practices (20 doctors). The main outcome measures were the antiretroviral treatment status of all patients who were eligible for treatment, and the disease stage and CD4(+) cell counts at the onset of therapy for patients who started treatment after publication of the 1991 guidelines. Results. For 472 patients, data were available on CD4(+)cell measurement status and disease stage. For 15.9% of patients, CD4(+) cells had never been measured; most of them were asymptomatic. In 84.1% of patients, CD4(+) cells had been measured. Of the 8.9% of patients whose results were not known to GPs, 93% were treated by a specialist and 76% were symptomatic. Of the remaining 355 (75.2%) patients whose CD4(+) count and disease status were known, 201 (56.7%) met the guideline criteria for treatment. Of these, 53.7% received treatment, 27.4% were never treated and 18.9% had discontinued treatment. Of the 67 patients who started treatment after publication of the guidelines, 36.2% of asymptomatic patients and 92.8% of symptomatic patients started later than the guidelines advised. Conclusion. In the population studied, we found a discrepancy between the 1991 treatment guidelines and the actual situation. In a substantial proportion of eligible patients, antiretroviral treatment was either not administered at all or was adminstered at a (very) late disease stage. This can only be attributed to physicians' and/or patients' attitudes towards antiretroviral treatment. Other studies confirm that a number of psychological factors may influence treatment decisions. The new combination treatment of HIV-infection requires an early start and compliance with the guidelines. The degree to which doctors and patients are willing and able to comply with the guidelines is an important factor to be taken into account, both in research and in the development of guidelines.