Abstract
Barriers to achieve sustained HIV virological suppression on antiretroviral therapy (ART) jeopardize the success of the 90:90:90 UNAIDS initiative which aims to end the HIV/AIDS epidemic. In France, where access to ART is free and universally available, we analyze the way in which social determinants of health (i.e. cultural, environmental) and economic factors might influence virological outcomes. A cross-sectional study was performed in two hospitals located in Paris area. All consecutive people living with HIV (PLHIV) on ART for at least 6 months attending the outpatient clinics between 01/05/2013 and 31/10/2014 answered an individual score of deprivation, EPICES, retrieving information on health insurance status, economic status, family support and leisure activity. This score varies from 0 to 100 with deprivation state defined above 30.17. Factors associated with HIV viral load >50 copies/ml were assessed by logistic regression modeling with a backward stepwise selection to select the final multivariable model. Sensitivity analyses were performed using two other thresholds for virological non-suppression (100 or 200 copies/ml). Overall, 475 PLHIV were included (53% male, median age 47 years, 66% not born in France mainly in a sub-Saharan African country). Half of French natives and 85% of migrants were classified as deprived. Median duration on ART was 9.7 years with virological suppression in 95.2% of non-deprived participants and in 83.5% of deprived ones (p = 0.001). The final multivariable model retained ART tiredness, younger age, a previous AIDS event and social deprivation (adjusted Odds Ratio, 2.9; 95%CI, 1.2–7.0) as determinants of virological non-suppression but not migration in itself. When using separate components of EPICES score, reporting economic difficulties and non-homeownership were associated with virological non-suppression. In addition to interventions focusing on cultural aspects of migration, social interventions are needed to help people with social vulnerability to obtain sustained responses on ART.
Highlights
Clinical prognosis and survival among people living with HIV (PLHIV) on antiretroviral therapy (ART) depend on sustained virological suppression and CD4 cell count recovery
In the French context of free universal access to care, we aimed to assess association between migration, socioeconomic status and virological suppression in PLHIV on ART in two hospitals located in Paris area
315 (66%) participants were not born in France, of whom 231 (73%) were born in sub-Saharan Africa (SSA), 18 (6%) in an European country, and 66 (21%) in another foreign country
Summary
Clinical prognosis and survival among people living with HIV (PLHIV) on antiretroviral therapy (ART) depend on sustained virological suppression and CD4 cell count recovery. In France, one study reported a higher risk of virological failure among heterosexual migrants mainly from SSA, in comparison with men having sex with men (MSM) [4], whereas other studies did not observe any differences between these two groups [5], or reported a higher risk of failure among non-homosexual men, whatever their geographic origin [6]. Whether this can be explained by different socioeconomic position, education or lifestyle is still questionable [7,8]. In the French context of free universal access to care, we aimed to assess association between migration, socioeconomic status and virological suppression in PLHIV on ART in two hospitals located in Paris area
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