Final Report Summary - HIVDIS (Impact of socio-economical inequalities in the progression of HIV infection at individual and contextual level in Europe)
In the current context of economic crisis, rising unemployment and cuts to health-care budgets in Europe, socio-economic inequalities among HIV infected patients in Europe should be carefully monitored to enable national and EU health planners to efficiently reach groups of vulnerable HIV-positive individuals.
Over the last 15 years, while cART was transforming HIV infection into a chronic disease, the HIV epidemic became a major health problem for disadvantaged socio-economic groups including young women and migrants from ethnic minorities. A substantial body of literature has demonstrated that adverse socio-economic conditions significantly affect health status among the general population and among persons affected by various chronic conditions including cardiovascular disease, diabetes, or cancer. On the other hand, to date there are no studies with sufficient sample size to explore the role of socioeconomic determinants and inequalities in health among HIV positive individuals in Europe. This information is however crucial for the European Union (EU) health care planners to understand and reduce barriers to HIV testing and to life-saving antiretroviral treatment.
The aim of the EU funded HIVDIS project was to use the data from the FP7-funded Eurocoord Network of Excellence (NoE) to study the role of the socio-economic status of HIV positive patients at the individual and contextual levels on health care outcomes in HIV positive patients: timely HIV diagnosis and initiation of antiretroviral therapy, response to treatment and disease progression. In particular, data from COHERE in EuroCoord, a collaboration of clinical cohorts of HIV positive patients receiving care in Western Europe between 1996 and 2011 were used for the project (http://www.chip.dk/COHERE/tabid/295/Default.aspx).
The project used the 2011 data from the COHERE in EuroCoord. Socio-economic variables were not collected in the COHERE in EuroCoord database that was used for the HIVDIS project. We have therefore collaborated with COHERE in EuroCoord to set up the retrospective collection of information on level of education and occupational level status and the city/town of the clinic as a proxy of the patients’ area of residence. A number of HIV cohorts in COHERE in EuroCoord collect socio-economic data, mainly on educational level. Only a few cohorts collect data on occupational status and income. Since socio-economic variables were collected in different formats and were not harmonized across cohorts and countries, we also collaborated with the EuroCoord NoE to propose unified definitions and common format for the socio-economic variables level of education and occupational status. Our proposed definitions were implemented in the HICDEP data exchange format (http://www.hicdep.org/wiki/Hicdep_1.70/TableBas) and are currently used by all European HIV cohorts. The merger of the socio-economic variables was completed in October 2012. The final dataset included data from 9 cohorts and approximately 20,000 patients with known educational level. To our knowledge, HIVDIS is the largest study on socio-economic status in HIV in Europe ever conducted. The variable maximum attained educational level was categorised as follows: uncompleted primary education, primary education, secondary education and tertiary education.
We used the COHERE in EuroCoord database to explore whether lower educational level, a proxy for socio-economic status, was associated with i) late HIV diagnosis, and ii) late cART initiation, the cornerstones of successful treatment cascade. The analysis included 15414 patients diagnosed with HIV between 1996 and 2011. Although access to HIV care is universal in Europe, we found clear trends of lower educational level being associated with delayed HIV diagnosis and ART initiation. We also found evidence of a weaker impact of less education on delayed HIV diagnosis in women than men, probably reflecting the universal opt-out HIV testing offered to all pregnant women in Europe. Finally, there was some evidence that delays in ART initiation in patients with lower educational level persisted also among patients whose HIV disease was not diagnosed late.
In a second study, we compared educational level groups in terms of clinical, immunological and virological response to antiretroviral treatment. The analysis included 14524 HIV positive patients in the COHERE in EuroCoord database who initiated ART between 1996 and 2011. We found that HIV-positive subjects with lower educational level, a proxy for poorer socio-economic status, had poorer clinical outcomes following ART – higher mortality and rate of new AIDS events and poorer virological and immunological responses. The observed trends by educational level were not fully explained by patients’ characteristics at ART initiation.
Overall, this study indicates that socio-economic inequalities in health are present in European countries with universal health care systems and that individuals with lower socio-economic status will not equally benefit from the effectiveness of ART. Policies and interventions that target socio-economic determinants leading to delays in HIV diagnosis and ART initiation are needed. Whether the observed inequalities are all avoidable, and thus amendable, is a discussion to be urgently advanced within the equity policy framework for Europe Health 202034 and more deeply taken into account in clinical and epidemiological research. The knowledge gained by this project underlines the importance to raise awareness on socio-economic inequalities in the ART era and to monitor its evolution in Western European countries.