Socio-economic Inequalities and HIV Working Group for Collaboration of Observational HIV Epidemiological Research in Europe (COHERE) in Euro-Coord. Inequalities by educational level in response to combination antiretroviral treatment and survival in HIV-positive men and women in Europe

The "Cycle" of HIV: Limits of Personal Responsibility in HIV Vulnerability Among Transgender Adolescents and Young Women in Lima, Peru

Globally, transgender women (TW) face a high burden of the HIV epidemic. In Peru, HIV prevalence among TW rises at age 25, indicating a need to understand HIV vulnerability as adolescents reach adulthood. The life course of TW is often marked by abuse, discrimination and poverty fueled by transphobic stigma. Approaches to the HIV epidemic among TW and adolescents emphasize problem behaviors such as unprotected sex and substance. However, there has been a call for HIV research and interventions to understand and leverage community strengths. This qualitative study utilized a transgender-oriented, strength-based, intersectional and feminist approach to understand the strengths and protective health behaviors among 17 transgender adolescents and young women (TAYW) age 16-24 in Lima, Peru. Most participants re-located to Lima from the Amazon due to familial rejection, and engaged in obligatory sex work. TAYW demonstrated self-knowledge, motivation for education, efforts to secure employment, strong community networks, legal advocacy, avoiding problem substance use, HIV knowledge and condom use. However, strengths were impeded by multi-level barriers such as familial physical abuse, educational discrimination, and sexual assault which led to increased HIV vulnerability. We created a conceptual model of the "cycle" of HIV to describe the limits of personal responsibility within a vulnerable community denied access to family, education, employment and human rights. We recommend researchers, clinicians and public health workers follow the lead of TAYW at the frontlines of the HIV epidemic, and support beloved communities and enabling environments which may permit protective behaviors to mitigate HIV vulnerability.

Viral load suppression and its predictor among HIV seropositive people who receive enhanced adherence counseling at public health institutions in Bahir Dar, Northwest Ethiopia. Retrospective follow-up study

BACKGROUND

For those HIV seropositive people with high viral loads, the World Health Organization recommends more counseling before changing ART regimens. A high viral load can lead to increased HIV transmission and lower survival rates. Clients with viral loads above 1000 copies/mL should receive enhanced adherence counseling for 3-6 months before switching. Despite enhanced adherence counseling programs, most countries struggle with viral load suppression. Little is known about viral load suppression in Ethiopia and the research area after counseling.

OBJECTIVE

This study aims to assess viral load suppression and its predictors among HIV-positive individuals receiving enhanced adherence counseling in Bahir Dar, Northwest Ethiopia, in 2022.

METHODS

An institution-based retrospective follow-up study was conducted among randomly selected 546 clients on Enhanced Adherence Counseling at public health facilities in Bahir Dar city. The Epicollect5 mobile application was used to collect the data, which was then exported to Stata version 14 for analysis. A Log-Binomial regression model was fitted for each explanatory variable. Variables having a p-value <0.25 in bivariate analysis were entered into a multivariable Log-Binomial regression model. Finally, an adjusted risk ratio with a 95% confidence interval and a p-value <0.05 was used to measure the strength of the prediction.

RESULTS

Following enhanced adherence counseling, 312 (57.1%) people had their viral load suppressed. Absence of recurrent OI (ARR 1.40; CI 1.03-1.91), EAC stay less than 3 months (ARR 1.54; CI 1.19-1.99), EAC stay 3-6 months (ARR 1.38; CI 1.12-1.69), once-daily ARV dose regimen (ARR 1.28; CI 1.03-1.58), baseline viral load of 2879.00 copies/ml (ARR 1.30, CI 1.06-1.60), being orthodox Tewahido Christian (ARR 0.37; CI 0.18-0.75) were significant predictors of viral load suppression after Enhanced Adherence Counseling.

CONCLUSION AND RECOMMENDATION

Most importantly, this study found that most people had suppressed viral loads after receiving enhanced adherence counseling. Significant predictors of viral load suppression included recurrent OI, length of stay on EAC, daily ARV dosing regimen, baseline viral load, and religion. Clients with a high baseline viral load and those who experience recurring opportunistic infections should get extra care during EAC sessions.

Factors Associated with Late Diagnosis of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) in a University Hospital in Brazil: Challenges to Achieving the 2030 Target

INTRODUCTION

This study aimed to identify factors associated with late diagnosis and clinically monitor newly diagnosed HIV/AIDS patients.

METHOD

Retrospective study, based on secondary data from a specialized unit at the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto of the University of Sao Paulo. Data collection included sociodemographic, behavioral, clinical, and laboratory data of newly diagnosed HIV patients between 2015 and 2019. Data analysis was undertaken using inferential statistical tests.

RESULTS

A total of 314 individuals were newly diagnosed with HIV/AIDS, 86.6% (272) had a late diagnosis and 53.8% (169) were diagnosed very late. Using the adjusted odds ratio, we observed that bisexual and MSM patients were less likely to have a late diagnosis compared to straight patients. Individuals who entered through the emergency department and Outpatient Clinic had a lower chance of having a very late diagnosis compared to those diagnosed in the ward/inpatient unit. Having a higher education and university education were protective factors against having a very late diagnosis of HIV infection compared to elementary school education only. In addition, male patients were more likely to have a very late diagnosis compared to female patients.

CONCLUSIONS

This study evidenced a high prevalence of late and very late diagnoses. Therefore, attention should be directed towards factors related to late and very late presentation.

Prevalence of HIV/AIDS Infection among Sexually Active Women in Ethiopia: Further Analysis of 2016 EDHS

Background

The issue of HIV/AIDS is prevalent around the world and in Ethiopia as well. The aim of this study was to determine the prevalence and risk factors of HIV/AIDS infection among sexually active women in Ethiopia.

Methods

For this study, data were obtained from the Ethiopia Demographic and Health Survey conducted in 2016. This study contains 11,729 women who have had at least one episode of sexual intercourse in their lifetime. Interviewers for voluntary HIV testing collected finger-prick blood specimens from women who agreed to be tested for HIV. Based on factors at the individual and community levels, a multilevel logistic regression model was used.

Results

The study found that 2% of 11,729 sexually active women tested positive for HIV from all regions who received voluntary counseling and testing. The intraclass correlation coefficient findings showed that 32.844% of HIV/AIDS transmission among sexually active women was the result of community-level factors. Variables at the individual level were women of age 16-24 (AOR = 0.18; 95% CI: 0.11-0.29), women of age 25-34 (AOR = 0.733; 95% CI: 0.55-0.98), women with primary education level (AOR = 1.8; 95% CI: 1.23-2.57), more than one sexual accomplice (AOR = 1.33; 95% CI: 0.613-2.87), and women's age at first sexual intercourse between 25 and 34 (AOR = 0.57, 95% CI: 0.301, 1.06); these were the most significant determinants of HIV/AIDS infection. According to community-level factors, there was a lower HIV prevalence rate among rural women (AOR = 0.22; 95 percent CI: 0.13-0.36), and women in the Gambela region (AOR = 4.1; 95 percent CI: 1.99-8.34) also had higher HIV prevalence rates.

Conclusions

The prevalence of HIV infection among sexually active women varies by region, with urban women more likely to contract the virus. Women who had more than one regular sexual partner and had their first sexual encounter at a younger age are at an increased risk of contracting HIV/AIDS. According to the study, the government should focus more support on high-risk clusters, mainly in urban areas, as well as on regions with high rates of HIV/AIDS infection.

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.

The impact of regional socioeconomic deprivation on the timing of HIV diagnosis: a cross-sectional study in Germany

BACKGROUND

HIV infections which are diagnosed at advanced stages are associated with significantly poorer health outcomes. In Germany, the proportion of persons living with HIV who are diagnosed at later stages has remained continuously high. This study examined the impact of regional socioeconomic deprivation on the timing of HIV diagnosis.

METHODS

We used data from the national statutory notification of newly diagnosed HIV infections between 2011 and 2018 with further information on the timing of diagnosis determined by the BED-Capture-ELISA test (BED-CEIA) and diagnosing physicians. Data on regional socioeconomic deprivation were derived from the German Index of Socioeconomic Deprivation (GISD). Outcome measures were a non-recent infection based on the BED-CEIA result or an infection at the stage of AIDS. The effect of socioeconomic deprivation on the timing of diagnosis was analysed using multivariable Poisson regression models with cluster-robust error variance.

RESULTS

Overall, 67.5% (n = 10,810) of the persons were diagnosed with a non-recent infection and 15.2% (n = 2746) with AIDS. The proportions were higher among persons with heterosexual contact compared to men who have sex with men (MSM) (76.8% non-recent and 14.9% AIDS vs. 61.7% non-recent and 11.4% AIDS). MSM living in highly deprived regions in the countryside (< 100 k residents) were more likely to have a non-recent infection (aPR: 1.16, 95% CI: 1.05-1.28) as well as AIDS (aPR: 1.41, 95% CI: 1.08-1.85) at the time of diagnosis compared to MSM in less deprived regions in the countryside. No differences were observed among MSM from towns (100 k ≤ 1 million residents) or major cities (≥ 1 million residents), and no differences overall in the heterosexual transmission group.

CONCLUSIONS

An effect of socioeconomic deprivation on the timing of HIV diagnosis was found only in MSM from countryside regions. We suggest that efforts in promoting HIV awareness and regular HIV testing are increased for heterosexual persons irrespective of socioeconomic background, and for MSM with a focus on those living in deprived regions in the countryside.

The impact of gender and the social determinants of health on the clinical course of people living with HIV in Myanmar: an observational study

BACKGROUND

There is a growing recognition of the impact of gender and the social determinants of health on the clinical course of people living with HIV (PLHIV). However, the relative contribution of these factors to clinical outcomes of PLHIV is incompletely defined in many countries. This study was performed to gain a greater understanding of the non-clinical determinants of prognosis of PLHIV in Myanmar.

METHODS

Selected demographic, behavioural and socioeconomic characteristics of outpatients at two specialist HIV hospitals and one general hospital in Yangon, Myanmar were correlated with their subsequent clinical course; a poor outcome was defined as death, hospitalisation, loss to follow-up or a detectable viral load at 6 months of follow-up.

RESULTS

221 consecutive individuals with advanced HIV commencing anti-retroviral therapy (ART) were enrolled in the study; their median CD4 T-cell count was 92 (44-158) cells/mm3, 138 (62.4%) were male. Socioeconomic disadvantage was common: the median (interquartile range (IQR) monthly per-capita income in the cohort was US$48 (31-77); 153 (69.9%) had not completed high school. However, in a multivariate analysis that considered demographic, behavioural, clinical factors and social determinants of health, male gender was the only predictor of a poor outcome: odds ratio (95% confidence interval): 2.33 (1.26-4.32, p = 0.007). All eight of the deaths and hospitalisations in the cohort occurred in males (p = 0.03).

CONCLUSIONS

Men starting ART in Myanmar have a poorer prognosis than women. Expanded implementation of gender-specific management strategies is likely to be necessary to improve outcomes.

Time spent with HIV-RNA ≤ 200 copies/ml in a cohort of people with HIV during the U=U era

OBJECTIVE

Zero risk of linked HIV transmission in serodiscordant couples when the HIV-infected partner had viral load less than 200 copies/ml ('U status') was found in observational studies. We aimed at estimating the proportion of time in which 'U status' was maintained and identifying factors associated with the risk of losing it.

DESIGN

Observational cohort study.

METHODS

We included participants in the ICONA cohort who had reached an established 'U status' (viral load ≤200 copies/ml for >6 months) as of December 2010. The outcome was the number of person-days of follow-up (PDFU) above a viral load greater than 200 copies/ml, relative to the total number of PDFU observed. A logistic regression model was used to identify factors independently associated with the risk of losing 'U status'.

RESULTS

Eight thousand, two hundred and forty-one persons living with HIV were included in the analysis who contributed 2 670 888 PDFU. Of these, 1648 (20%) were women, 768 (9%) were people who inject drugs (PWID), and 2066 (25%) were foreign-born. The median of viral load measurements was 9 (IQR: 4-15). Overall, only 3.1% of PDFU were observed when viral load was above 200 copies/ml. The proportion of PDFU with viral load more than 200 copies/ml was higher than average in women (5.3%), unemployed (5.4%), PWID (4.7%), and in people with more than three previous virologic failures (6.3%). These variables were significant predictors of losing 'U status' in the multivariable logistic regression.

CONCLUSION

Our results reinforce the validity of the U=U message in real-world setting. However, we identified subsets of our study population at higher risk of losing the 'U status' for whom additional efforts are needed.

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.

Elevated risk of viral rebound on ART in migrants living in France: role of socioeconomic factors

BACKGROUND

In Western countries, viral rebound on antiretroviral therapy (ART) appears to occur more frequently in migrants. We aimed to assess the respective roles of socioeconomic factors and migration on viral rebound in people living with HIV (PLHIV) in France.

METHODS

We included PLHIV in France, enrolled from 2004 to 2008 in the French ANRS-COPANA cohort, who started a first ART and achieved undetectability (<50 copies/ml) within 1 year. Determinants of viral rebound were assessed using Cox models including geographical origin, HIV transmission group, and clinicobiological and sociodemographic data.

RESULTS

Of 499 included individuals, 288 were born in France, 158 in sub-Saharan Africa (SSA) and 53 in another country. Kaplan-Meier probabilities of viral rebound-free survival were similar for men having sex with men (MSM) and heterosexuals born in France, and lower in migrants from SSA or other countries (P<0.001). The crude hazard ratio (HR) of viral rebound was 2.49 (95% CI, 1.59, 3.90) in migrants from SSA and 1.78 (0.94, 3.88) in migrants from other countries compared with MSM born in France. Educational level, financial difficulties and HIV status disclosure had the biggest impact on the difference between the crude and adjusted HRs for viral rebound in migrants. In multivariable analysis, viral rebound was no longer associated with geographical origin, but with protease inhibitor-containing ART, a VACS index ≥35 as a potential indicator of frailty, poor financial status (difficulties or debts) and non-disclosure to friend(s).

CONCLUSIONS

Socioeconomic factors affect outcomes on ART, even in the context of free access to HIV care and treatment. Patient-centred strategies should be encouraged with the intervention of social workers to address basic needs and promote social support for more socially vulnerable individuals.

Population attributable fractions of mortality in people living with HIV: roles of delayed antiretroviral therapy, hepatitis coinfections and social factors

OBJECTIVES

Despite free access to antiretroviral therapy (ART) from 1996 onward, and treatment for all people living with HIV (PLWHIV) from 2013, mortality in Brazil has not homogeneously decreased. We investigated to what extent delayed ART, hepatitis coinfections and sociodemographic factors predict all-cause mortality in Brazilian PLWHIV.

DESIGN

We included PLWHIV at least 18 years, with complete CD4 cell count data, followed up between 2007 and 2015 in Brazil.

METHODS

After multiple imputation, an extended Cox model helped estimate the effects of fixed and time-varying covariates on mortality.

RESULTS

The study population (n = 411 028) were mainly male (61%), white (55%), 40 years or less (61%), heterosexually HIV infected (71%), living in the Southeast region (48%) and had basic education (79%). Hepatitis C virus and hepatitis B virus coinfection prevalences were 2.5 and 1.4%, respectively. During a 4-year median follow-up, 61 630 deaths occurred and the mortality rate was 3.45 (95% confidence interval: 3.42-3.47) per 100 person-years. Older age, male sex, non-white ethnicity, illiteracy/basic education and living outside the Southeast and Central-West regions were independently associated with increased mortality. The main modifiable predictors of mortality were delayed ART (i.e. CD4 cell count <200 cells/μl at ART initiation) (adjusted population attributable fraction: 14.20% [95% confidence interval: 13.81-14.59]), being ART-untreated (14.06% [13.54-14.59]) and ART-treated with unrecorded CD4 at ART initiation (5.74% [5.26-6.21]). Hepatitis C virus and hepatitis B virus coinfections accounted for 2.44 [2.26-2.62] and 0.42% [0.31-0.53] of mortality, respectively.

CONCLUSION

The current study demonstrates that besides early ART and coinfection control, actions targeting males, non-whites and illiterate people and those with basic education are important to reduce avoidable deaths among Brazilian PLWHIV.

Racial Differences in Change in Physical Functioning in Older Male Veterans with HIV

Little is known about longitudinal change in physical functioning of older African American/Black and White HIV-infected persons. We examined up to 10 years of data on African American (N = 1,157) and White (N = 400) men with HIV infection and comparable HIV-negative men (n = 1,137 and 530, respectively), age 50-91 years from the Veterans Aging Cohort Study Survey sample. Physical functioning was assessed using the SF-12 (12-Item Short Form Health Survey) physical component summary (PCS) score. Mixed-effects models examined association of demographics, health conditions, health behaviors, and selected interactions with PCS score; HIV biomarkers were evaluated for HIV-infected persons. PCS scores were approximately one standard deviation below that of the general U.S. population of similar age. Across the four HIV/race groups, over time and through ages 65-75 years, PCS scores were maintained; differences were not clinically significant. PCS score was not associated with race or with interactions among age, race, and HIV status. CD4 and viral load counts of African American and White HIV-infected men were similar. Older age, low socioeconomic status, chronic health conditions and depression, lower body mass index, and smoking were associated with poorer PCS score in both groups. Exercising and, counterintuitively, being HIV infected were associated with better PCS score. Among these older African American and White male veterans, neither race nor HIV status was associated with PCS score, which remained relatively stable over time. Chronic disease, depression, and lack of exercise were associated with lower PCS score. To maintain independence in this population, attention should be paid to controlling chronic conditions, and emphasizing good health behaviors.

Respective roles of migration and social deprivation for virological non-suppression in HIV-infected adults on antiretroviral therapy in France

Barriers to achieve sustained HIV virological suppression on antiretroviral therapy (ART) jeopardize the success of the 90:90:90 UNAIDS initiative which aims to end the HIV/AIDS epidemic. In France, where access to ART is free and universally available, we analyze the way in which social determinants of health (i.e. cultural, environmental) and economic factors might influence virological outcomes. A cross-sectional study was performed in two hospitals located in Paris area. All consecutive people living with HIV (PLHIV) on ART for at least 6 months attending the outpatient clinics between 01/05/2013 and 31/10/2014 answered an individual score of deprivation, EPICES, retrieving information on health insurance status, economic status, family support and leisure activity. This score varies from 0 to 100 with deprivation state defined above 30.17. Factors associated with HIV viral load >50 copies/ml were assessed by logistic regression modeling with a backward stepwise selection to select the final multivariable model. Sensitivity analyses were performed using two other thresholds for virological non-suppression (100 or 200 copies/ml). Overall, 475 PLHIV were included (53% male, median age 47 years, 66% not born in France mainly in a sub-Saharan African country). Half of French natives and 85% of migrants were classified as deprived. Median duration on ART was 9.7 years with virological suppression in 95.2% of non-deprived participants and in 83.5% of deprived ones (p = 0.001). The final multivariable model retained ART tiredness, younger age, a previous AIDS event and social deprivation (adjusted Odds Ratio, 2.9; 95%CI, 1.2–7.0) as determinants of virological non-suppression but not migration in itself. When using separate components of EPICES score, reporting economic difficulties and non-homeownership were associated with virological non-suppression. In addition to interventions focusing on cultural aspects of migration, social interventions are needed to help people with social vulnerability to obtain sustained responses on ART.

Influence of geographic origin on AIDS and serious non-AIDS morbidity/mortality during cART among heterosexual HIV-infected men and women in France

BACKGROUND

The influence of geographic origin on the risk of severe illness and death on cART has not been explored in European countries.

METHOD

We studied antiretroviral-naïve heterosexual HIV-1-infected individuals enrolled in the FHDH-ANRS CO4 cohort in France who started cART between 2006 and 2011. Individuals originating from France (French natives), sub-Saharan Africa (SSA) and non-French West-Indies (NFW) were studied until 2012. Crude and adjusted rate ratios (aRR) of severe morbid events/deaths (AIDS-related and non-AIDS-related) were calculated using Poisson regression models stratified by sex, comparing each group of migrants to French natives.

RESULTS

Among 2334 eligible men, 1379 (59.1%) originated from France, 838 (35.9%) from SSA and 117 (5.0%) from NFW. SSA male migrants had a higher aRR for non-AIDS infections, particularly bacterial infections (aRR 1.56 (95% CI 1.07-2.29), p = 0.0477), than French natives. Among 2596 eligible women, 1347 (51.9%) originated from France, 1131 (43.6%) from SSA, and 118 (4.5%) from NFW. SSA and NFW female migrants had a higher aRR for non-AIDS infections, particularly non-bacterial infections (respectively, 2.04 (1.18-3.53) and 7.87 (2.54-24.4), p = 0.0010), than French natives. We observed no other significant differences related to geographic origin as concerns the aRRs for AIDS-related infections or malignancies, or for other non-AIDS events/deaths such as cardiovascular disease, neurological/psychiatric disorders, non-AIDS malignancies and iatrogenic disorders, in either gender.

CONCLUSION

Heterosexual migrants from SSA or NFW living in France have a higher risk of non-AIDS-defining infections than their French native counterparts. Special efforts are needed to prevent infectious diseases among HIV-infected migrants.

Impact of social determinants on antiretroviral therapy access and outcomes entering the era of universal treatment for people living with HIV in Italy

BACKGROUND

Social determinants are known to be a driving force of health inequalities, even in high income countries. Aim of our study was to determine if these factors can limit antiretroviral therapy (ART) access, outcome and retention in care of people living with HIV (PLHIV) in Italy.

METHODS

All ART naïve HIV+ patients (pts) of Italian nationality enrolled in the ICONA Cohort from 2002 to 2016 were included. The association of socio-demographic characteristics (age, sex, risk factor for HIV infection, educational level, occupational status and residency area) with time to: ART initiation (from the first positive anti-HIV test), ART regimen discontinuation, and first HIV-RNA < 50 cp/mL, were evaluated by Cox regression analysis, Kaplan Meier method and log-rank test.

RESULTS

A total of 8023 HIV+ pts (82% males, median age at first pos anti-HIV test 36 years, IQR: 29-44) were included: 6214 (77.5%) started ART during the study period. Women, people who inject drugs (PWID) and residents in Southern Italy presented the lowest levels of education and the highest rate of unemployment compared to other groups. Females, pts aged > 50 yrs., unemployed vs employed, and people with lower educational levels presented the lowest CD4 count at ART initiation compared to other groups. The overall median time to ART initiation was 0.6 years (yrs) (IQR 0.1-3.7), with a significant decrease over time [2002-2006 = 3.3 yrs. (0.2-9.4); 2007-2011 = 1.0 yrs. (0.1-3.9); 2012-2016 = 0.2 yrs. (0.1-2.1), p < 0.001]. By multivariate analysis, females (p < 0.01) and PWID (p < 0.001), presented a longer time to ART initiation, while older people (p < 0.001), people with higher educational levels (p < 0.001), unemployed (p = 0.02) and students (p < 0.001) were more likely to initiate ART. Moreover, PWID, unemployed vs stable employed, and pts. with lower educational levels showed a lower 1-year probability of achieving HIV-RNA suppression, while females, older patients, men who have sex with men (MSM), unemployed had higher 1-year risk of first-line ART discontinuation.

CONCLUSIONS

Despite median time to ART start decreased from 2002 to 2016, socio-demographic factors still contribute to disparities in ART initiation, outcome and durability.

Sub-Saharan African migrants have slower initial CD4+ cell recovery after combined antiretroviral treatment initiation than French natives

OBJECTIVE

Poorer immunologic responses to combined antiretroviral treatment (cART) have been reported among sub-Saharan African (SSA) migrants than among native Europeans. We studied whether differences in CD4 cell recovery between French natives and SSA migrants starting first-line cART could be explained by differences in socioeconomic conditions, inflammatory marker levels, and other established determinants.

METHODS

We compared 319 French natives and 175 SSA migrants (ANRS-COPANA cohort). Clinical, biological, and socioeconomic data (education, employment, income, and cohabiting partnership) were recorded at regular visits. A piecewise linear mixed-effects model was used to analyze CD4 cell count kinetics on cART.

RESULTS

Compared with French natives, SSA migrants were more frequently women, younger, less educated, living in more adverse conditions, and had more frequent symptoms of depression. The rate of CD4 cell recovery during the first 4 months on cART was significantly slower in SSA migrants, despite a similar virologic response, but did not differ significantly thereafter. The mean CD4 cell count rose from 251 cells/μl at baseline to 508 cells/μl at 36 months in migrants, and from 308 to 623 cells/μl in natives (additional mean gain of 58 cells/μl in natives). The difference persisted after adjustment for clinical, updated socioeconomic, and living conditions (-0.40√CD4 cells/month, P = 0.04); 25-hydroxyvitamin D, monocyte chemoattractant protein-1 and soluble tumor necrosis factor receptor 1 (sTNFR1) levels were lower in SSA migrants, but only sTNFR1 contributed to the difference in CD4 slope.

CONCLUSION

Initial CD4 cell recovery on cART was slower among SSA migrants than among French natives. This difference was not explained by established clinical and biological determinants or by socioeconomic status.

How are women living with HIV in France coping with their perceived side effects of antiretroviral therapy? Results from the EVE study

OBJECTIVE

Side effects of antiretroviral therapy (ART) can have a negative impact on health-related quality of life threatening long-term retention in HIV care and adherence to ART. The aim of the French community-based survey EVE was to document personal experiences with side effects, the related physician-patient communication, and solutions found to deal with them.

DESIGN

Cross-sectional study of women between September 2013 to September 2014.

METHODS

An anonymous online questionnaire included the HIV Symptom Distress Module, which explores 20 symptoms.

RESULTS

In all, 301 women on ART participated in the study (median age: 49 years; median duration of ART: 14 years). They reported having experienced a median of 12 symptoms (Q1-Q3: 9-15) during the previous 12 months. Overall, 56% of them reported having found at least a partial solution to dealing with their symptoms. Women reporting financial difficulties were twice less likely to have found solutions to coping with their side effects (AOR: 0.5; 95% CI: 0.3-0.8). Feeling supported by the health-care provider (AOR: 2.1; 95% CI: 1.1-3.9) and being in contact with HIV/AIDS organisations (AOR: 1.9; 95% CI: 1.2-3.2) were positively associated with coping. Seventeen percent reported having modified their ART regimen to improve tolerance, with only 2 in 3 informing their physician afterwards. Reporting financial difficulties and living with more bothersome symptoms increased the risk of ART regimen modification without health-care provider consultation.

CONCLUSION

The EVE study has called attention to the large number of side effects experienced by WLWHIV, only half of whom have found self-care strategies to manage their symptoms. Modification of ART regimen by the women themselves was not uncommon.