Abstract
SummaryBackgroundFew studies have assessed the effect of socioeconomic status on HIV treatment outcomes in settings with universal access to health care. Here we aimed to investigate the association of socioeconomic factors with antiretroviral therapy (ART) non-adherence, virological non-suppression, and virological rebound, in HIV-positive people on ART in the UK.MethodsWe used data from the Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) questionnaire study, which recruited participants aged 18 years or older with HIV from eight HIV outpatient clinics in the UK between Feb 1, 2011, and Dec 31, 2012. Participants self-completed a confidential questionnaire on sociodemographic, health, and lifestyle issues. In participants on ART, we assessed associations of financial hardship, employment, housing, and education with: self-reported ART non-adherence at the time of the questionnaire; virological non-suppression (viral load >50 copies per mL) at the time of questionnaire in those who started ART at least 6 months ago (cross-sectional analysis); and subsequent virological rebound (viral load >200 copies per mL) in those with initial viral load of 50 copies per mL or lower (longitudinal analysis).FindingsOf the 3258 people who completed the questionnaire, 2771 (85%) reported being on ART at the time of the questionnaire, and 2704 with complete data were included. 873 (32%) of 2704 participants reported non-adherence to ART and 219 (9%) of 2405 had virological non-suppression in cross-sectional analysis. Each of the four measures of lower socioeconomic status was strongly associated with non-adherence to ART, and with virological non-suppression (prevalence ratios [PR] adjusted for gender/sexual orientation, age, and ethnic origin: greatest financial hardship vs none 2·4, 95% CI 1·6–3·4; non-employment 2·0, 1·5–2·6; unstable housing vs homeowner 3·0, 1·9–4·6; non-university education 1·6, 1·2–2·2). 139 (8%) of 1740 individuals had subsequent virological rebound (rate=3·6/100 person-years). Low socioeconomic status was predictive of longitudinal rebound risk (adjusted hazard ratio [HR] for greatest financial hardship vs none 2·3, 95% CI 1·4–3·9; non-employment 3·0, 2·1–4·2; unstable housing vs homeowner 3·3, 1·8–6·1; non-university education 1·6, 1·1–2·3).InterpretationSocioeconomic disadvantage was strongly associated with poorer HIV treatment outcomes in this setting with universal health care. Adherence interventions and increased social support for those most at risk should be considered.FundingNational Institute for Health Research.
Highlights
Substantial evidence exists of socioeconomic inequalities in the prognosis of chronic diseases
With data from the Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) study, we aimed to investigate the association of socioeconomic factors with antiretroviral therapy (ART) non-adherence, virological non-suppression, and virological rebound, in HIV-positive people on ART in the UK
Study design and participants ASTRA is a cross-sectional, questionnaire study of 3258 HIV-diagnosed individuals in the UK recruited from eight HIV outpatient clinics between Feb 1, 2011, and Dec 31, 2012.22 Participants self-completed a confidential questionnaire on sociodemographic, health, and lifestyle issues
Summary
Substantial evidence exists of socioeconomic inequalities in the prognosis of chronic diseases. In Europe and the USA, socioeconomic factors such as poverty, low income, and low education level have been associated with poorer outcomes for several diseases, including cancer, and cardiovascular disease.[1,2,3] Findings of other studies have suggested that lower socioeconomic status (measured by education or income) is associated with poorer adherence to treatment, such as steroids for asthma[4] and insulin for diabetes.[5]. HIV is a disease that disproportionately affects those with socioeconomic disadvantage.[6] In the USA, in people with HIV receiving antiretroviral therapy (ART), lower levels of socioeconomic status (as indicated by lower education level, unemployment, homelessness, or household poverty) are associated with having poorer virological and immunological outcomes.[7,8,9,10,11] HIV-positive populations in the UK and Europe comprise distinct demographic groups, with substantial variation in social circumstances. In contrast to the USA, the UK has universal free access to health care, including HIV diagnosis, hospital consultations, and antiretroviral treatment, which should greatly lessen financial barriers
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