In the current era of universal treatment, fewer and fewer clinicians caring for people with HIV are advising their patients to delay taking antiretroviral (ARV) medications.

Before 2009, U.S. treatment guidelines recommended beginning ARVs when CD4 counts dropped below 350; then, in 2009, treatment was suggested when CD4s dropped below 500; and finally, in 2012, treatment was advised at any CD4 count.

Deferral of ARV treatment can apply to those who have and have not yet taken HIV treatment.

Researchers analyzed 2009 to 2014 data on a cohort of individuals who represented a cross section of the population receiving care for HIV in the United States. During this time, the proportion of people with HIV who received a deferral for ARV treatment decreased from 12 percent to 4 percent.

In 2009, reported reasons for delaying HIV treatment included the health care provider’s recommendation (67 percent), feeling healthy (9 percent), medication side effects (7 percent) and other reasons (13 percent).

In 2014, reported top reasons for treatment deferrals included the provider’s recommendation (40 percent), feeling healthy (14 percent), side effects (7 percent), other reasons (25 percent) and money or insurance (14 percent).

“People reporting non-provider-advised ART [ARV treatment] deferral were more likely to be depressed, binge drink, use illicit drugs and not be virally suppressed,” says the study’s first author, Linda Beer, PhD, an epidemiologist in the Centers for Disease Control and Prevention’s Division of HIV/AIDS Prevention. “As such, increased access to mental health and substance counseling and treatment could be critical to improving treatment adherence and achieving universal ART for all clinically eligible people with HIV.”