Abstract
BackgroundSocial determinants are known to be a driving force of health inequalities, even in high income countries. Aim of our study was to determine if these factors can limit antiretroviral therapy (ART) access, outcome and retention in care of people living with HIV (PLHIV) in Italy.MethodsAll ART naïve HIV+ patients (pts) of Italian nationality enrolled in the ICONA Cohort from 2002 to 2016 were included. The association of socio-demographic characteristics (age, sex, risk factor for HIV infection, educational level, occupational status and residency area) with time to: ART initiation (from the first positive anti-HIV test), ART regimen discontinuation, and first HIV-RNA < 50 cp/mL, were evaluated by Cox regression analysis, Kaplan Meier method and log-rank test.ResultsA total of 8023 HIV+ pts (82% males, median age at first pos anti-HIV test 36 years, IQR: 29–44) were included: 6214 (77.5%) started ART during the study period. Women, people who inject drugs (PWID) and residents in Southern Italy presented the lowest levels of education and the highest rate of unemployment compared to other groups. Females, pts aged > 50 yrs., unemployed vs employed, and people with lower educational levels presented the lowest CD4 count at ART initiation compared to other groups. The overall median time to ART initiation was 0.6 years (yrs) (IQR 0.1–3.7), with a significant decrease over time [2002–2006 = 3.3 yrs. (0.2–9.4); 2007–2011 = 1.0 yrs. (0.1–3.9); 2012–2016 = 0.2 yrs. (0.1–2.1), p < 0.001]. By multivariate analysis, females (p < 0.01) and PWID (p < 0.001), presented a longer time to ART initiation, while older people (p < 0.001), people with higher educational levels (p < 0.001), unemployed (p = 0.02) and students (p < 0.001) were more likely to initiate ART. Moreover, PWID, unemployed vs stable employed, and pts. with lower educational levels showed a lower 1-year probability of achieving HIV-RNA suppression, while females, older patients, men who have sex with men (MSM), unemployed had higher 1-year risk of first-line ART discontinuation.ConclusionsDespite median time to ART start decreased from 2002 to 2016, socio-demographic factors still contribute to disparities in ART initiation, outcome and durability.
Highlights
Social determinants are known to be a driving force of health inequalities, even in high income countries
Demographic and socio-behavioral data, initiation and discontinuation dates of each antiretroviral drug, Human Immunodeficiency Virus (HIV)-viral load and CD4 cell count every 3–6 months, AIDS defining diseases according to Centers for Disease Control and Prevention (CDC) criteria as well as non-HIV related diseases and death are recorded for all enrolled participants
Baseline patient characteristics A total of 8023 HIV-positive patients (82% males, median age at first positive anti-HIV test: 36 years, Interquartile range (IQR): 29–44) were included in the Italian Cohort Naïve Antiretrovirals (ICONA) observational database in the period 2002–2016, whose characteristics are shown in Table 1, overall and according to the three different study periods
Summary
Social determinants are known to be a driving force of health inequalities, even in high income countries. Aim of our study was to determine if these factors can limit antiretroviral therapy (ART) access, outcome and retention in care of people living with HIV (PLHIV) in Italy. Barriers to ART access for PLHIV do exist, with important differences among countries, especially according to socio-economic levels and organization models of national healthcare systems [2]. These disparities can affect the probability of reaching the “90–90-90” target fixed by UNAIDS for 2030 (90% diagnosed individuals of all PLHIV, 90% treated patients, and 90% PLHIV achieving viral suppression) [3]. Entering the era of universal ART for all HIV people living with HIV, we can hypothesize that these factors could have an even greater impact on disparities in ART access compared to past years
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