Socioeconomic position and ten-year survival and virologic outcomes in a Ugandan HIV cohort receiving antiretroviral therapy.

Andrew G Flynn,Frank Mubiru,Godwin Anguzu,Agnes N Kiragga,David B Meya,Barbara C Castelnuovo,David R Boulware,Moses Kamya,Andrew Kambugu,Giuseppe Vittorio De Socio

doi:10.1371/journal.pone.0189055

Andrew G Flynn, Frank Mubiru + Show 8 more

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https://doi.org/10.1371/journal.pone.0189055

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Abstract

Lifelong ART is essential to reducing HIV mortality and ending the epidemic, however the interplay between socioeconomic position and long-term outcomes of HIV-infected persons receiving antiretroviral therapy (ART) in sub-Saharan Africa is unknown. Furthering the understanding of factors related to long-term ART outcomes in this important region will aid the successful scale-up of ART programs. We enrolled 559 HIV-infected Ugandan adults starting ART in 2004–2005 at the Infectious Diseases Institute in Kampala, Uganda and followed them for 10 years. We documented baseline employment status, regular household income, education level, housing description, physical ability, and CD4 count. Viral load was measured every six months. Proportional hazard regression tested for associations between baseline characteristics and 1) mortality, 2) virologic failure, and 3) mortality or virologic failure as a composite outcome. Over ten years 23% (n = 127) of participants died, 6% (n = 31) were lost-to-follow-up and 23% (107/472) experienced virologic treatment failure. In Kaplan-Meier analysis we observed an association between employment and mortality, with the highest cumulative probability of death occurring in unemployed individuals. In univariate analysis unemployment and disease severity were associated with mortality, but in multivariable analysis the only association with mortality was disease severity. We observed an association between higher household income and an increased incidence of both virologic failure and the combined outcome, and an association between self-employment and lower incidence of virologic failure and the combined outcome when compared to unemployment. Formal education level and housing status were unrelated to outcomes. It is feasible to achieve good ten-year survival, retention-in-care, and viral suppression in a socioeconomically diverse population in a resource-limited setting. Unemployment appears to be related to adverse 10-year ART outcomes. A low level of formal education does not appear to be a barrier to successful long-term ART.

Highlights

These African studies did not account for physical ability and disability, which is related to disease progression and death in people living with HIV, and may be related to socioeconomic position.[29]
Despite the fact that viral monitoring is the most objective measure of antiretroviral therapy (ART) adherence and subsequent treatment success, regional literature examining socioeconomic position and viral suppression is limited to one 2003 South African study which reported no association between socioeconomic position and one-year viral suppression when ART was provided free of charge.[30]
In Kaplan-Meier analysis, sex and employment status were associated with loss to follow-up, with men and unemployed individuals most likely to be lost from the cohort

Summary

Introduction

Socioeconomic position—an aggregate of resources including education, employment, income and wealth that interact but are not interchangeable—is linked to health outcomes in a variety of diseases and settings.[1,2,3,4] Among HIV-infected individuals receiving antiretroviral therapy (ART) in high-income countries, less wealth, income or formal education conveys risk for poorer survival.[5,6,7,8,9,10,11] food insecurity, less formal education and homelessness conveys risk for decreased viral suppression in high-income countries.[5, 12, 13] HIV/AIDS is the leading cause of death in sub-Saharan Africa and the number of individuals receiving ART is increasing,[14, 15] any relationship between socioeconomic position and ART outcomes in this important region is poorly understood.Scale-up of ART and viral load monitoring in sub-Saharan Africa is recent and limited[15] and, as a result, most literature on socioeconomic determinants examines pre-ART outcomes. Regional literature indicates higher socioeconomic position may convey an increased risk of HIV infection among the general population and, among HIV-infected individuals in care before starting ART, lower socioeconomic position may convey an increased risk of loss-tofollow-up and death.[16,17,18,19,20,21,22,23,24,25] The limited literature examining socioeconomic position and ART outcomes in Africa is plagued by short follow-up times. Despite the fact that viral monitoring is the most objective measure of ART adherence and subsequent treatment success, regional literature examining socioeconomic position and viral suppression is limited to one 2003 South African study which reported no association between socioeconomic position and one-year viral suppression when ART was provided free of charge.[30]

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