The influence of the patients’ educational levels on socioeconomic, clinical, immunological and virological endpoints

Progress Towards UNAIDS's 95-95-95 Targets in Zimbabwe: Sociodemographic Constraints and Geospatial Heterogeneity

The HIV/AIDS epidemic remains critical in sub-Saharan Africa, with UNAIDS establishing "95-95-95" targets to optimize HIV care. Using the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) geospatial data, this study aimed to identify patterns in these targets and determinants impacting the HIV care continuum in underserved Zimbabwean communities. Analysis techniques, including Gaussian kernel interpolation, optimized hotspot, and multivariate geospatial k-means clustering, were utilized to establish spatial patterns and cluster regional HIV care continuum needs. Further, we investigated healthcare availability, access, and social determinants and scrutinized the association between socio-demographic and behavioral covariates with HIV care outcomes. Disparities in progress toward the "95-95-95" targets were noted across different regions, with each target demonstrating unique geographic patterns, resulting in four distinct clusters with specific HIV care needs. Key factors associated with gaps in achieving targets included younger age, male sex, employment, and minority or no religious affiliation. Our study uncovers significant spatial heterogeneity in the HIV care continuum in Zimbabwe, with unique regional patterns in "95-95-95" targets. The spatial analysis of the UNAIDS targets presented here could prove instrumental in designing effective control strategies by identifying vulnerable communities that are falling short of these targets and require intensified efforts. Our result provides insights for designing region-specific interventions and enhancing community-level factors, emphasizing the need to address regional gaps and improve HIV care outcomes in vulnerable communities lagging behind.

HIV Care Outcomes in Relation to Racial Redlining and Structural Factors Affecting Medical Care Access Among Black and White Persons with Diagnosed HIV-United States, 2017

Black/African American (Black) versus White persons are unequally burdened by human immunodeficiency virus (HIV) in the United States. Structural factors can influence social determinants of health, key components in reducing HIV-related health inequality by race. This analysis examined HIV care outcomes among Black and White persons with diagnosed HIV (PWDH) in relation to three structural factors: racial redlining, Medicaid expansion, and Ryan White HIV/AIDS Program (RWHAP) use. Using National HIV Surveillance System, U.S. Census, and Home Mortgage Disclosure Act data, we examined linkage to HIV care and viral suppression (i.e., viral load < 200 copies/mL) in relation to the structural factors among 12,996 Black and White PWDH with HIV diagnosed in 2017/alive at year-end 2018, aged ≥ 18 years, and residing in 38 U.S. jurisdictions with complete laboratory data, geocoding, and census tract-level redlining indexes. Compared to White PWDH, a lower proportion of Black PWDH were linked to HIV care within 1 month after diagnosis and were virally suppressed in 2018. Redlining was not associated with the HIV care outcomes. A higher prevalence of PWDH residing (v. not residing) in states with Medicaid expansion were linked to HIV care ≤ 1 month after diagnosis. A higher prevalence of those residing (v. not residing) in states with > 50% of PWDH in RWHAP had viral suppression. Direct exposure to redlining was not associated with poor HIV care outcomes. Structural factors that reduce the financial burden of HIV care and improve care access like Medicaid expansion and RWHAP might improve HIV care outcomes of PWDH.

Influence of Material Deprivation on Clinical Outcomes Among People Living with HIV in High-Income Countries: A Systematic Review and Meta-analysis

Despite developments in HIV treatment and care, disparities persist with some not fully benefiting from improvements in the HIV care continuum. We conducted a systematic review to explore associations between social determinants and HIV treatment outcomes (viral suppression and treatment adherence) in high-income countries. A random effects meta-analysis was performed where there were consistent measurements of exposures. We identified 83 observational studies eligible for inclusion. Social determinants linked to material deprivation were identified as education, employment, food security, housing, income, poverty/deprivation, socioeconomic status/position, and social class; however, their measurement and definition varied across studies. Our review suggests a social gradient of health persists in the HIV care continuum; people living with HIV who reported material deprivation were less likely to be virologically suppressed or adherent to antiretrovirals. Future research should use an ecosocial approach to explore these interactions across the lifecourse to help propose a causal pathway.

Association between social support and viral load in adults on highly active antiretroviral therapy - Witbank, South Africa

BACKGROUND

There are significant number of patients who are on highly active antiretroviral therapy (HAART) not virally suppressed, which is a huge clinical challenge. Social support as a non-pharmacological factor, which may influence the viral suppression, is less studied and has equivocal results. The aim of this study was to investigate the association between social support and viral load (VL) in adults on HAART.

METHODS

This was an analytical cross-sectional study. Using a structured questionnaire, 380 adults (≥ 18 years) on HAART for ≥ 6 months were recruited between November 2018 and February 2019 from Witbank hospital and surrounding clinics. Multivariable logistic regression was carried out.

RESULTS

The mean age of the participants was 40.5 years (s.d. = 10.3). The majority were females (73%), at least high school educated (84%), unemployed (57%), single (63%) and did not have comorbidity (80%). The vast majority had moderate to high adherence (84%) and moderate to good perceived social support (94%). The viral suppression rate was 87%. Both adherence (p 0.001) and social support (p = 0.017) were significantly associated with VL. However, only adherence was predictive of viral suppression in multivariable analysis. Compared to poorly adherent, moderately (OR = 2.8; 95% CI = 1.32-5.98) and highly (OR = 5.3; 95% CI = 2.41-11.81) adherent participants were more likely to have suppressed VL.

CONCLUSION

Viral suppression rate was high. Self-reported adherence to HAART was highly predictive of viral suppression, which highlights the importance of assessing and addressing adherence issues at every contact with patients taking HAART. Good social support did not predict viral suppression.

Inequalities by educational level in response to combination antiretroviral treatment and survival in HIV-positive men and women in Europe

BACKGROUND

Socioeconomic inequality challenges population-level implementation of health interventions. We investigated differences by educational level in clinical, virological, and immunological responses to combined antiretroviral treatment (cART) in HIV-positive men and women in Collaboration of Observational HIV Epidemiological Research in Europe, a European collaboration.

METHODS

Data were pooled from 15 cohorts in eight countries of patients initiating cART in 1996-2013 with data on educational level categorized in UNESCO/ISCED classifications. Kaplan-Meier curves, Cox and piecewise linear mixed models were used.

RESULTS

Of 24 069 HIV-positive patients, 9% had not completed primary education, 32% had completed primary, 44% secondary, and 15% tertiary education. Overall, 21% were women, who were overrepresented in lower educational strata. During 132 507 person-years of follow-up, 1081 individuals died; cumulative mortality decreased with higher educational level (P < 0.001). Over 122 765 person-years, new AIDS events or death occurred in 2598 individuals; differences by education were more marked than for death alone (P < 0.001). Virological response was achieved by 67% of patients without completed basic education, 85% with completed primary education, 82% with secondary, and 87% with tertiary (P < 0.001). Patients with higher education had higher CD4 cell count at cART initiation and at each time after cART but rate of CD4 cell count recovery did not differ. Differences in mortality and clinical responses were similar for men and women and were not entirely explained by delayed HIV diagnosis and late cART initiation.

CONCLUSION

HIV-positive patients with lower educational level had worse responses to cART and survival in European countries with universal healthcare. To maximize the population impact of cART, Europe needs to decrease the socioeconomic divide.

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

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.

Determinants of virological response to antiretroviral therapy: socio-economic status still plays a role in the era of cART. Results from the ANRS-VESPA 2 study, France

BACKGROUND

Disparities in combined antiretroviral therapy (cART) outcomes have been consistently reported among people living with HIV (PLWHIV). The present study aims at investigating the mechanisms underlying those disparities among PLWHIV in France.

METHODS

We used data from the Vespa2 survey, a large national cross-sectional survey, representative of HIV-infected people followed at hospitals in 2011. Among participants diagnosed ≥1996, HIV treatment-naive at the time of cART initiation and on cART for at least 12 months, the frequency of sustained virological suppression (SVS; undetectable viral load [<50 copies/ml] for at least 6 months) at the time of the survey, was assessed and its social determinants were measured through logistic regression, accounting for clinical and biological determinants of response to cART.

RESULTS

Among 1,246 participants, 77.7% had achieved SVS. SVS was less frequent among those unemployed (0.6 [range 0.3-1.0]) and those with the lowest level of education (0.4 [range 0.2-0.9]). The late presenters, diagnosed at a CD4⁺ T-cell count <200/mm³ (0.5 [range 0.3-0.9]) and the late starters, diagnosed at a CD4⁺ T-cell count >200 but initiating cART at CD4⁺ T-cell count <200 (0.3 [range 0.1-0.8]) were less likely than the ideal starters (≥350 CD4⁺ T-cells/mm³ at cART initiation) to achieve SVS, as were those who reported suboptimal adherence versus those reporting optimal adherence (0.4 [range 0.2-0.7]). In bivariate analyses, material deprivation, discrimination and a weak social network were also associated with a poorer treatment response.

CONCLUSIONS

Structural social factors remain strong determinants of treatment response and should be addressed in a broad approach of care, but wider political issues should also be investigated.

The relationship between adherence to clinic appointments and year-one mortality for newly enrolled HIV infected patients at a regional referral hospital in Western Kenya, January 2011-December 2012

This retrospective cohort analysis was conducted to describe the association between adherence to clinic appointments and mortality, one year after enrollment into HIV care. We examined appointment-adherence for newly enrolled patients between January 2011 and December 2012 at a regional referral hospital in western Kenya. The outcomes of interest were patient default, risk factors for repeat default, and year-one risk of death. Of 582 enrolled patients, 258 (44%) were defaulters. GEE revealed that once having been defaulters, patients were significantly more likely to repeatedly default (OR 1.4; 95% CI 1.12-1.77), especially the unemployed (OR 1.43; 95% CI 1.07-1.91), smokers (OR 2.22; 95% CI 1.31-3.76), and those with no known disclosure (OR 2.17; 95% CI 1.42-3.3). Nineteen patients (3%) died during the follow-up period. Cox proportional hazards revealed that the risk of death was significantly higher among defaulters (HR 3.12; 95% CI 1.2-8.0) and increased proportionally to the rate of patient default; HR was 4.05 (95% CI1.38-11.81) and 4.98 (95% CI 1.45-17.09) for a cumulative of 4-60 and ≥60 days elapsed between all scheduled and actual clinic appointment dates, respectively. Risk factors for repeat default suggest a need to deliver targeted adherence programs.

Role of Education in HIV Clinical Outcomes in a Tuberculosis Endemic Setting

This study evaluated how educational attainment impacts clinical outcomes of HIV-positive patients in Durban, South Africa. The authors conducted a prospective study of 466 adult HIV-positive patients initiating antiretroviral therapy (ART) at an urban TB-HIV clinic from October 2004 to June 2007. The level of educational attainment (highest grade completed) was assessed at ART initiation. The authors measured tuberculosis treatment outcomes as well as death, lost to follow-up, viral suppression (HIV RNA <400 copies/mL), and immunologic response (CD4 ≥200 cells/mm(3)) at 6, 12, and 24 months after ART initiation. After 24 months of ART initiation, there were 43 deaths; viral suppression and immunologic response were observed in 88% and 83% of the remaining patients, respectively. The authors found no association between level of educational attainment and mortality (P = .12), loss to follow-up (P = .85), virologic response (P = .51), or immunologic response (P = .63). Similar findings were observed at 6 and 12 months post-ART initiation.

Socioeconomic Status and Survival of People with Human Immunodeficiency Virus Infection before and after the Introduction of Highly Active Antiretroviral Therapy: A Systematic Literature Review

BACKGROUND

Human immunodeficiency virus/acquired immunodeficiency disease syndrome-associated mortality contributes considerably to overall mortality rates among adults in the United States. The purpose of this review is to systematically examine conceptual approaches that have been used to evaluate the association between socioeconomic status of people infected with human immunodeficiency virus and their survival and summarize existing evidence regarding the association between socioeconomic status and mortality due to human immunodeficiency virus/acquired immunodeficiency disease syndrome.

METHODS

We systematically retrieved neighborhood and individual-level studies of acquired immunodeficiency disease syndrome-related or all-cause mortality among patients diagnosed with human immunodeficiency virus that reported original data and analyzed socioeconomic status as a predictor of mortality.

RESULTS

We included 21 studies (19 cohort and 2 case-control studies). Heterogeneity in both the conceptual approaches to socioeconomic status measurements and selection of variables for the adjustment of the measure of association precluded meta-analysis of the results. Six studies observing populations before the introduction of highly active antiretroviral therapy found that socioeconomic status was not associated with human immunodeficiency virus/acquired immunodeficiency disease syndrome mortality. In the post- highly active antiretroviral therapy period socioeconomic status was inconsistently associated with Human immunodeficiency virus/acquired immunodeficiency disease syndrome mortality risk in studies adjusting for highly active antiretroviral therapy use.

CONCLUSION

Further studies considering multilevel socioeconomic status measurements and controlling for treatment and clinical variables are needed to enhance understanding of the role of socioeconomic gradients on human immunodeficiency virus outcomes.

"I didn't know that ..." patient perceptions of print information, education, and communication related to HIV/AIDS treatment

Improving health literacy is a necessary intervention for people with chronic health conditions to ensure adherence with long or life therapies and increase participation in self-care. While adherence is a multifactorial process, increasing health literacy among HIV-infected patients at all stages of living with HIV has been shown to improve treatment outcomes. In the era of rapid scale up of HIV care and treatment, little has been done to evaluate the utility of information, education, and communication (IEC) materials for increasing patient health literacy and how patients perceive such materials. Four patient-oriented print IEC brochures in Kiswahili were designed to be read at the clinic waiting areas and also carried home by patients to supplement the knowledge received from routine counselling during clinic visits. Brochures detail antiretroviral therapy and address common myths, side effects, types and management of opportunistic infections, and prevention of mother to child transmission of HIV. We conducted focus group discussions with HIV-infected patients to explore patient perceptions of IEC materials in the urban congested HIV care setting of Dar es Salaam, Tanzania. Groups of participants were recruited from eight public PEPFAR-supported HIV care and treatment centres in the city (N = 50). In this paper we present the results of those focus group discussions and introduce the print IEC materials as a pilot intervention in a Kiswahili-speaking setting where a need for additional health literacy exists. Further evaluation of these materials will follow as the data becomes available.