Table 4.

HIV providers’ decision-making factors and priorities for ART initiation among young people with behaviorally acquired HIV

Theme 1: Determining the Role of the CD4 Count in Deciding ART Initiation
1a	“I think there’s guidelines and then there’s the patient…Decisions are still individual decisions and I try to include the patients...It’s not like [a CD4 count of] 500 is a magic number. I think there are a lot of other factors that go into that decision.”
	Physician, Internal Medicine
1b.	“I think everybody should be on antiretroviral therapy but, you know, the urgency of that is dependent on CD4. So someone below 200 I think absolutely needs it quickly; somebody in the 200–350 range needs it soon, 350–500 needs it…but I would be willing to wait if I was concerned about adherence and, above 500, would view it as being an option for people who are motivated and likely to be adherent.”
	Physician, Internal Medicine
1c.	“I think personally I would not do that [start ART for everyone]…we're talking about somebody who's probably not adherent and not going to be taking medicines, or on and off, developing a resistant virus, who then will be transmitting this resistant virus to others… personally to me, that trade-off is not very well balanced.”
	Physician, Medicine-Pediatrics
1d.	“I've had patients [with] normal T-cells…[who] just didn't want there to be a possibility…to pass onto his partner if the condom were to break or anything like that…If there's high-risk sexual activity, sex workers…if there's no other barriers to adherence and they're going to take it the way they're supposed to, then I'd like to get them started too, to prevent transmission.”
	Physician, Family Practice
Theme 2: Balancing Tension Between Clinical Status and Concern for ART Non-Adherence
2a	“If they have AIDS, you know, then I think that they would probably benefit from therapy even if they’re not completely adherent…I don't think I would make them prove to me that they can be adherent...The higher the CD4 count is…the more I focus on, you know, making sure the patient is adherent before I start the therapy. So it varies depending on their stage.”
	Physician, Internal Medicine
2b	“No, if someone can’t take their meds, we don’t give them their meds, no matter what their CD4 is. No matter if they’ve had pneumocystis. Because it doesn’t help them. They just give resistance. Just makes the doctor feel like she’s doing something.”
	Physician, Family Practice
2c	“Is there anybody you’ve told about your HIV?….Does the person have any place stable to sleep? Do they have…food? Are they…in and out of jail?...In terms of HAART, it’s stuff that’s going to completely get in the way of them being able to adhere to a HAART regimen.”
	Physician, Pediatrics
2d	“So if they're good at taking their birth control pills, or they can take a vitamin every day…then I'm willing to start the process of getting them on HAART…Do they even keep the appointment with the pharmacy adherence team? If they don't keep that appointment, then we may need to reconsider starting them because they're not showing that they're up to their medical care.”
	Physician, Family Practice
Theme 3: Defining “Patient Readiness” and the Impact on ART Initiation
3a	“When a patient comes in saying, ‘I’m really ready to get started on medications. I want to take them every day... I don’t want to risk getting sick…I’ve been really adherent with my other medicines. I never miss any doses.’ That kind of language…That’s a patient who’s ready to start.”
	Physician Assistant, Adult Practice
3b	“You think someone's ready, [but] I got burned a couple of weeks ago with one of our youth…very articulate, educated guy…He's able to really convince you that he understands what's going on, he understands the gravity…Guess what? He took Atripla and two months into it…find out his viral load is 62,000. So again, it's a judgment call, that's why they call it an art…You become convinced and you're not right.”
	Physician, Medicine-Pediatrics
3c	“Somebody who I just can’t get to come into clinic despite all of our best efforts, who just sort of shows up out of the blue once a year, I mean, I just don’t see how writing them a prescription is going to help… But even in the setting where I feel like there’s no way in hell they’re going to take this medication at all on a regular basis, that severe immunosuppression or recent severe illness has made me just try it anyway. [Interviewer: And what have you found those outcomes tend to be?] Horrible. So, in the end, I’m treating myself in some ways more than them, I think.”
	Physician, Pediatrics
Theme 4: Identifying Youth-Specific Adherence Concerns
4a	“I’m not sure if it’s because [older people] are used to going to the doctor, whereas the new generation or the younger generation, this may be their first time in a doctor’s office since their pediatrician…the older patient population...understand health a little bit better...they’re just usually overall more adherent.”
	Nurse Practitioner, Adult Practice
4b	“I find it's like with some of the young ones, communication is the issue. They don’t communicate well or they don’t have the foresight because they don’t have the experience of even taking medications before, much less a chronic medication.”
	Physician Assistant, Adult Practice
4c	“They say all the right things, they want to be treated; they’re very gung ho, and then I never see them again…that’s a much more common scenario to me than older people and so I’m always a little careful to not believe everything I hear. It’s true for everybody, but a young person can really be there at one moment and then move onto something else pretty quickly.”
	Physician, Internal Medicine
4d	“I think the primary thing I’ve noticed is just more of an erratic schedule for younger patients compared to someone who is older and has more of an established routine. And maybe more tendency to travel and potentially forget medications at home, things of that nature and maybe trying to hide things from friends or family because they’re not totally comfortable even in their own skin.”
	Physician, Internal Medicine
Theme 5: Being Aware of the Developing Youth
5a	“The young adult is a different host altogether, because they're still growing and still experimenting and testing the waters, so that makes it a little difficult in honing in on whether you would treat or not to treat… they don't have the life skills onboard…and like any child they don't look beyond yesterday, or tomorrow's not even in the equation. It's today, here and now, and trying to get a young person to understand that taking this [medicine] makes a difference and tomorrow is different.”
	Nurse Practitioner, Adult Practice
5b	“I find they're learning about dating, they're learning about drinking, they're learning about drug use, they're learning about sex, they're learning about all those kinds of things…I had a kid, 22-year-old…in his first relationship... And I tossed the whole plan for that visit out the window to deal with that, because I thought it was huge for him….you've got to dig a little bit for it…help them peel the onion a little bit and pull it down, see what's going on.”
	Physician Assistant, Adult Practice
5c	“Then there was just a turning point, for him, personally. He wanted to be more mature and he wanted to start medicines…And so we started him on medicines and he's done fine since then, you know?…Maybe it was just him coming to a point where he felt mature enough to take medicines.”
	Physician, Medicine-Pediatrics
Theme 6: Working Effectively with BHIV Youth in Care
6a	“I like the fact that I’m working with them as they emerge into adulthood to figure out who they are… I see these kids who come in just disasters and destined for what looks like bad outcomes, who just really manage to bit-by-bit pull it together, often with a lot of support from our team. To be able to talk to them, get to know them, see them mature and to progress over that time is really gratifying.”
	Physician, Pediatrics
6b	“I think they have a greater ability to adapt and change… It feels good to work with them because you can help optimize their health for the long term where, sometimes in the older adults, they have a lot of other comorbidities, and you can control their HIV but it’s hard to manage all their other comorbidities.”
	Physician, Internal Medicine
6c	“I think the ones that we’ve stayed on top of and trying to make sure that they get into their visits…the case managers calling them, making sure that we’re arranging for transportation to get into their clinics is big…Almost like that hypervigilant follow up is key…Also when you’re able to do the comprehensive care…making sure everybody is taking care of them and has a pulse on how they’re doing can make a big difference.”
	Physician Assistant, Adult Practice
6d	“I enjoy working with young patients, but for the ones who are truly still kind of adolescent in their development, I don’t feel like I have a great deal of expertise, and I --probably unlike a true adolescent expert --tend to expect them to behave like adults, and when they don’t, I don’t do a whole lot of the kind of modification that might happen in a pediatric clinic.”
	Physician, Internal Medicine