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.

It has been shown that socioeconomic factors are associated with the prognosis of several chronic diseases; however, there is no recent systematic review of their effect on HIV treatment outcomes. We aimed to review the evidence regarding the existence of an association of socioeconomic status with virological and immunological response to antiretroviral therapy (ART). We systematically searched the current literature using the database PubMed. We identified and summarized original research studies in high-income countries that assessed the association between socioeconomic factors (education, employment, income/financial status, housing, health insurance, and neighbourhood-level socioeconomic factors) and virological response, immunological response, and ART nonadherence among people with HIV-prescribed ART. A total of 48 studies met the inclusion criteria (26 from the United States, six Canadian, 13 European, and one Australian), of which 14, six, and 35 analysed virological, immunological, and ART nonadherence outcomes, respectively. Ten (71%), four (67%), and 23 (66%) of these studies found a significant association between lower socioeconomic status and poorer response, and none found a significant association with improved response. Several studies showed that adjustment for nonadherence attenuated the association between socioeconomic status and ART response. Our review provides strong support that socioeconomic disadvantage is associated with poorer response to ART. However, most studies have been conducted in settings such as the United States without universal free healthcare access. Further study in settings with free access to ART could help assess the impact of socioeconomic status on ART outcomes and the mechanisms by which it operates.

IntroductionIn the United Kingdom, rates of virological suppression on antiretroviral therapy (ART) are very high, but there remain a small but significant number of people on ART with detectable viraemia. The impact of socio-economic factors on virological suppression has been little studied.Materials and MethodsWe used data from ASTRA, a cross-sectional, questionnaire study of >3000 individuals from 8 clinics in the United Kingdom in 2011–2012, linked to clinical records to address this question. Included participants had received ART for >6 months with a recorded current viral load (VL) (latest at the time of questionnaire). Participants provided data on demographic factors: gender, sexual orientation, ethnicity and age; and socio-economic factors: UK birth/English reading ability, employment, housing, education and financial hardship. To assess non-adherence, participants were asked if in the past 3 months, they had missed ART for ≥2 days at a time. Virological suppression was defined as VL≤50 cps/mL. For each socio-economic factor, we calculated prevalence ratios using modified Poisson regression, first adjusting for demographic factors, then also for non-adherence.ResultsA total of 2445 people fulfilled the inclusion criteria (80% male, 69% MSM, median age: 46 years, median CD4 count: 556 cells/mm3); 10% (234/2445) had VL>50 cps/mL. After adjusting for demographic factors, non-fluent English, not being employed, not home owning, education below university level and increasing financial hardship were each associated with higher prevalence of VL>50 cps/mL. Additional adjustment for non-adherence largely attenuated each association, but did not fully explain them (see Table 1). After adjustment for non-adherence and demographic factors, younger age was also associated with VL>50 cps/mL: for each additional 10 years an individual was 0.80 (95% CI 0.70–0.92) times as likely to have VL>50 cps/mL (p=0.0019). Adjusted prevalence ratios for VL>50cps/mL were 0.91 (0.62–1.34) for women and 1.25 (0.85–1.84) for non-MSM men versus MSM, and 1.29 (0.92–1.80) for white versus non-white people. ConclusionsAmong people on ART in the United Kingdom, the proportion with detectable VL is low. Poorer socio-economic status is associated with increased probability of virological non-suppression. It is likely that much of this association is mediated through difficulties in taking ART. Emphasis should be put on aiding the adherence of people in these higher risk groups.

Where available, antiretrovirals (ARVs) and antenatal HIV testing and care have significantly reduced mother to child transmission (MTCT). Higher maternal viral load (VL) is linked with higher risk of MTCT, increasing risk of MTCT for women starting ARVs during pregnancy compared to those already suppressed.A single-centre, retrospective cohort of women starting ARVs during pregnancy from 2004 till 2013. Demographic, obstetric and virological data, and neonatal outcomes were collected where available.60 pregnancies were recorded (in 56 women) in which ARVs were started or restarted from a total of 129 recorded pregnancies. 48% (27/56) were new antenatal HIV diagnoses and in these median gestational age (GA) at diagnosis was 16.1 weeks (range 5.3-37.6). Median GA at ARV commencement was 22.4 weeks (range 8-37.7) with 63% (35/56) starting before 24 weeks and 91% (51/ 56) before 28 weeks. HIV diagnosis during pregnancy was associated with a later commencement of ARVs (23.9 vs 19.9 weeks, p=0.009). The ARV regimen was available for 58 pregnancies. Treatment was with two NRTIs plus NNRTI (3), or PI (54) or raltegravir (1). Raltegravir was added as a forth agent in 7 patients. 87% (52/60) had resistance genotyping before (14) or during (38) pregnancy, 81% (22/27) for new diagnoses in pregnancy. The rate of any ARV resistance was 12% (6/52): 4 patients had NNRTI and 2 NRTI resistance mutations, 4 were treatment-naïve. This was not associated with treatment failure.HIV VL at delivery was available in 57 pregnancies with detectable VL in 16% (9/57). Pre-treatment VL >100,000 copies/mL during pregnancy was associated with higher risk of detectable VL at delivery (p=0.016). 69% babies were delivered by Caesarean section, 32% as an emergency. There was one late miscarriage at 17 weeks. Median GA at birth was 38 weeks (range 17-42) with 21% born at <37 weeks (10/48). There was one HIV MTCT (1.7% for those starting ARV in pregnancy, 0.8% overall) in a woman who was poorly adherent with ARVs throughout pregnancy with a VL of 216 copies/mL at delivery following a period of directly observed therapy.Over 10 years of integrated HIV and antenatal care, there was only one case of MTCT. Initiating ART for prevention of MTCT is complex, requires a multi-disciplinary approach and importantly patient engagement. Antenatal practices and guidelines have changed over the period of this dataset, allowing normalisation of pregnancy when HIV is diagnosed and treated early.