Physicians who specialize in treating HIV-infected patients juggle patients' day-to-day concerns with results from clinical trials when selecting highly active antiretroviral therapy (HAART) regimens, according to a report released on Tuesday. Dr. Harold Kessler of Rush-Presbyterian-St. Luke's Medical Center in Chicago surveyed 279 physicians who were experienced in treating HIV infection. The respondents had an average of 182 HIV-seropositive patients in their practices. Physicians believe they "need to fit the regimen into the patient's lifestyle to meet the needs of the regimen, or else it is doomed to fail," Kessler said during a teleconference on Tuesday.

The main factor that influenced selection of an initial regimen was the "patient's ability to adhere," followed by viral load and CD+ cell count. Nearly one-third of physicians said they do not start a patient on a first regimen until they perceive the patient "to be ready to handle the therapy and take it seriously." Despite recent epidemiological information suggesting that some treatment-naive patients have resistant strains of HIV, most physicians said this has little or no impact on their practice. Even for patients failing a first-line regimen, only 56 percent of physicians said they always use a genotypic or phenotypic assay to guide their selection of the second-line therapy.

Most respondents restricted the use of four drugs as first-line therapy to patients with very high viral loads and very low CD4 counts, which is what existing studies advise, Kessler said. At an AIDS conference in Argentina in July, investigators evaluated four-drug versus three-drug regimens by looking at the kinetics of viral clearance. "They were able to show that patients are getting more rapid clearance, suggesting that there's greater potency. The issue is whether that translates into a better long-term outcome," Kessler said. "The survey tells us that there's more work to do in terms of resistance testing, understanding what the results are telling us and how better to use that information to treat patients who are failing therapy," Kessler said.

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