Combination antiretroviral therapy: health care providers confront emerging dilemmas

Recent editorials, conferences and clinical practice articles have discusse d providers' concerns and practices regarding prescribing antiretroviral co mbination therapy for HIV. We aimed to deepen our understanding of these la rgely anecdotal reports and of the challenges facing experienced HIV/clinic ians today using qualitative methodology. Eight-focus groups using a struct ured discussion guide were conducted. Data were analyzed by constant compar ative analysis and open codes. Participants were a diverse group of 23 phys icians, eight nurse practitioners and four physician assistants with signif icant experience providing care to HIV-seropositive patients in various San Francisco Bay Area health care settings. The following major themes emerge d from the data: (I) providers expressed new optimism about helping HIV-ser opositive patients live; (2) the main factors affecting providers' decision s about when to start combination therapy were the risks versus benefits of delaying therapy, and patients' health status, readiness to adhere and tre atment preferences; (3) providers lacked resources to prepare patients to b egin therapy and enhance adherence; (4) providers varied regarding assessme nt of adherence; and (5) providers were anxious about making decisions unde r conditions of uncertainty and were concerned about patient health outcome s. We concluded that experienced HIV clinicians were hopeful and excited ab out their increasing ability to help patients. This hope, however, was temp ered by scepticism about the future and by their daily struggles to make tr eatment decisions under conditions of great uncertainty. Without access to adjunct supports or a multidisciplinary team, providers may not be able to optimally assess and enhance antiretroviral medication adherence.