Socioeconomic status and treatment outcomes for individuals with HIV on antiretroviral treatment in the UK: cross-sectional and longitudinal analyses

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.

Out of focus: tailoring the cascade of care to the needs of women living with HIV

“…Data from the UK‐based Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) study again suggest that socioeconomic factors play a role in the observed gender differences in virological responses to ART . Through a survey of participants at eight UK clinics, who had been receiving ART for at least 6 months, the ASTRA study found that women were less likely to have enough money for basic needs than men – one of several socioeconomic factors that was linked to women having a greater likelihood of having a detectable viral load and experiencing viral load rebound after suppression than their male counterparts.…”

Accuracy of self‐report of HIV viral load among people with HIV on antiretroviral treatment

“…Exclusion criteria were as follows: age < 18 years; unable to understand the study questionnaire (available in English or French) because of language or cognitive difficulties; too ill or distressed to complete the questionnaire. Participants self‐completed a confidential paper questionnaire that included items on demographics (gender/sexual orientation; age; ethnicity), socioeconomic factors (UK birth/English fluency; education; employment; housing; financial hardship; supportive network assessed by a modified version of the Duke Functional Social Support questionnaire), HIV‐related factors (stable partner and their HIV status; disclosure of HIV status; ART use; ART start date; ART adherence), health‐related factors (symptoms of depression and anxiety as assessed by the Patient Health Questionnaire, 9 item scale [PHQ‐9] and the Generalized Anxiety Disorder 7 item scale [GAD‐7] , respectively); treatment for depression.…”

The effect of socioeconomic disadvantage on strategies to end the AIDS epidemic

“…If we fail to address social disadvantage in its many manifestations, we risk exacerbating health inequities. This is not a new phenomenon; the link between income and survival was prospectively observed early in the epidemic (25), nor, as noted by Burch and colleagues, is it limited to HIV (13). Clearly, indirect investments of socioeconomic status will be needed – and as Thoreau notes, these will not come cheap.…”

“…In this issue of the Lancet Public Health, Lisa Burch and colleagues (13) reported that among people treated for HIV in the United Kingdom, lower socio-economic status (i.e. financial hardship, non-employment, rented/unstable housing status, and no university education) were strongly associated with HAART non-adherence and virological non-suppression.…”

“…Among those who were virally suppressed at baseline, each marker of lower socio-economic status noted above was predictive of subsequent virological rebound. As the authors note, in this universal healthcare setting these findings suggest that the implications of poorer socioeconomic status “clearly go beyond lack of ability to pay for treatment and healthcare, and operate strongly even amongst those who are engaged with clinical care” (13). …”