title: Reasons for not starting antiretroviral therapy in HIV-1-infected individuals: a changing landscape.
abstract: OBJECTIVE
  A cross-sectional survey was conducted to better understand why chronically HIV-1-infected individuals stratified by CD4 count (≤349; 350-499; ≥500 cells/μL) were not on antiretroviral therapy (ART).
  
  
  METHODS
  Before the consultation, treatment-naive patients and their physicians independently completed a 90-item-questionnaire about barriers and their readiness to start/defer ART. The study was carried out at 34 sites in nine countries in Europe and Australia.
  
  
  RESULTS
  Between December 2011 and October 2012, 508 pairs of patient- and physician-questionnaires were completed. 426 (84 %) patients were male and 39 (8 %), 138 (27 %), and 330 (65 %) were in the three stratified groups based on CD4 count, respectively. In the category 'Body and symptoms' the most commonly identified reason for patients not to start was: "As long as I feel good I don't have to take medication" (44 %). Less than 20 % of respondents indicated fears of side effects and toxicity or problems to manage pills. Most patients were in the lowest stage of treatment-readiness (N = 323, 68 %), especially patients with CD4 cells ≥500 cells/μL (N = 240, 79 %). Physicians answered in 92 (18 %) cases that ART was not indicated for CD4 cells <500 cells/μL. Main reasons for physicians not starting treatment for these patients were their perception that patients were 'too depressed' (13 %) or that they had not known them long enough (13 %).
  
  
  CONCLUSIONS
  Nowadays patient-barriers to ART are commonly related to health-and treatment-beliefs compared to fear of toxicity or ART manageability in the past. This new barrier pattern seems to reflect the era of well tolerated, easier ART regimens and has to be considered in light of the new recommendations to treat all HIV-infected individuals regardless of the CD4 cell count.
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland. jan.fehr@usz.ch.
authors.forename: Jan
authors.initials: J
authors.lastname: Fehr
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland.
authors.forename: Dunja
authors.initials: D
authors.lastname: Nicca
authors.affiliation: Internal Medicine AIDS Reference Centre ULB-Hôpital Erasme, Brussels, Belgium.
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Goffard
authors.affiliation: Positive Council Switzerland, Zurich, Switzerland.
authors.forename: David
authors.initials: D
authors.lastname: Haerry
authors.affiliation: Gilead Sciences, Foster city, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Schlag
authors.affiliation: 5th Department of Medicine and Infectious Diseases Unit, "Evangelismos" General Hospital, Athens, Greece.
authors.forename: Vasileios
authors.initials: V
authors.lastname: Papastamopoulos
authors.affiliation: Department of Internal Medicine and Infectious Diseases, University Medical Utrecht, Utrecht, The Netherlands.
authors.forename: Andy
authors.initials: A
authors.lastname: Hoepelman
authors.affiliation: 5th Department of Medicine and Infectious Diseases Unit, "Evangelismos" General Hospital, Athens, Greece.
authors.forename: Athanasius
authors.initials: A
authors.lastname: Skoutelis
authors.affiliation: Gilead Sciences, Foster city, USA.
authors.forename: Ruth
authors.initials: R
authors.lastname: Diazaraque
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
authors.forename: Bruno
authors.initials: B
authors.lastname: Ledergerber
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000008:administration & dosage* / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology*; D015497:HIV-1; D006801:Humans; D008297:Male; D008875:Middle Aged; D011795:Surveys and Questionnaires; D061665:Time-to-Treatment / Q000706:statistics & numerical data*
chemical_list: D044966:Anti-Retroviral Agents
keywords: Antiretroviral treatment start; Barriers; HIV-infection