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

Abstract

Background: Few 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.

Methods: We 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).

Findings: Of 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).

Interpretation: Socioeconomic 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.

Funding: National Institute for Health Research.

Figure 1

Prevalence of (A) antiretroviral therapy (ART) non-adherence and (B) virological non-suppression (viral load >50 copies per mL), by socioeconomic and demographic factors (A) Data taken from a cross-sectional analysis in 2704 respondents who were on ART at the time of the questionnaire. Self-reported ≥2 consecutive missed days of ART in the past 3 months or ≥1 missed dose in the last 2 weeks. (B) Data taken from a cross-sectional analysis in 2405 respondents who were on ART and had started ART >6 months before the viral load measurement. MSM=men who have sex with men. *Calculated with Cochran-Armitage test for trend. †Calculated with χ² test.

Figure 2

Kaplan-Meier plots of time until virological rebound (viral load >200 copies per mL) according to (A) ability to afford basic needs (financial hardship), (B) employment status, (C) housing status, and (D) university education Longitudinal analysis in 1740 respondents on ART with viral load <50 copies per mL at the time of the questionnaire. Individuals with missing values were excluded. Numbers provided indicate the number of individuals at risk.