Patients' preferences regarding the timing of highly active antiretroviral therapy initiation for chronic asymptomatic HIV-1 infection

Objective: In patients with a chronic asymptomatic HIV-1 infection and >200 CD4(+) T-cells/mu l, the optimal timing of highly active antiretroviral therapy (HAART) initiation is unclear. It involves a trade-off between a potentially reduced risk of mortality, when started earlier in the course of infection, and an earlier exposure to pill burden and potential toxicities. We investigated patients' preferences for immediate HAART initiation relative to delaying HAART for 1 year. Methods: Consecutive patients were asked for their preference during an interview. A hypothetical difference in 3-year mortality risk between both options was systematically varied between 0% and 10% to determine the threshold at which preference would switch to HAART initiation. Results: About 30% of patients preferred HAART initiation even if the mortality risk would be equal for both options. Almost 25% always preferred delaying HAART even if this would result in a 10% greater mortality risk. Most treatment guidelines recommend delaying HAART >350 CD4(+) T-cells/mu l. However, at a risk difference between starting and delaying HAART that corresponds with this CD4(+) T-cell count, about 50% would prefer to start HAART immediately. Most guidelines recommend starting HAART below 200 CD4(+) T-cells/mu l. However, at a risk difference between both options corresponding with this CD4(+) T-cell count, about 40% preferred delaying HAART. Conclusions: We found large variation in patients' preferences. Some patients were more inclined to initiate HAART earlier than the recommended guidelines, whereas others were more inclined to delay HAART. These findings emphasize the need for shared decision-making when deciding on the most optimal timing of HAART initiation in chronic asymptomatic HIV-1 infection