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-inf ection, which advise that therapy be started at a peripheral blood CD4(+) c ell 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-infect ed patients registered in 14 Amsterdam general practices (20 doctors). The main outcome measures were the antiretroviral treatment status of all patie nts who were eligible for treatment, and the disease stage and CD4(+) cell counts at the onset of therapy for patients who started treatment after pub lication of the 1991 guidelines. Results. For 472 patients, data were available on CD4(+)cell measurement st atus 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(+) cell s had been measured. Of the 8.9% of patients whose results were not known t o GPs, 93% were treated by a specialist and 76% were symptomatic. Of the re maining 355 (75.2%) patients whose CD4(+) count and disease status were kno wn, 201 (56.7%) met the guideline criteria for treatment. Of these, 53.7% r eceived treatment, 27.4% were never treated and 18.9% had discontinued trea tment. Of the 67 patients who started treatment after publication of the gu idelines, 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 1 991 treatment guidelines and the actual situation. In a substantial proport ion of eligible patients, antiretroviral treatment was either not administe red at all or was adminstered at a (very) late disease stage. This can only be attributed to physicians' and/or patients' attitudes towards antiretrov iral treatment. Other studies confirm that a number of psychological factor s may influence treatment decisions. The new combination treatment of HIV-i nfection requires an early start and compliance with the guidelines. The de gree 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 researc h and in the development of guidelines.