Date Published: March 7, 2019
Publisher: Public Library of Science
Author(s): Mariem Raho-Moussa, Marguerite Guiguet, Céline Michaud, Patricia Honoré, Christia Palacios, François Boué, Mohammed Azghay, Imad Kansau, Véronique Chambrin, Tania Kandel, Marion Favier, Elsa Miekoutima, Naomi Sayre, Carole Pignon, Michka Shoai, Olivier Bouchaud, Sophie Abgrall, Justyna Dominika Kowalska.
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.
Clinical prognosis and survival among people living with HIV (PLHIV) on antiretroviral therapy (ART) depend on sustained virological suppression and CD4 cell count recovery. However, social determinants of health (ie cultural, environmental) and economic factors might influence outcomes after ART initiation. In Europe, poorer virological response on ART has been observed in migrants from sub-Saharan Africa (SSA) compared to non-migrant people [1–3]. In France, one study reported a higher risk of virological failure among heterosexual migrants mainly from SSA, in comparison with men having sex with men (MSM) , whereas other studies did not observe any differences between these two groups , or reported a higher risk of failure among non-homosexual men, whatever their geographic origin . Whether this can be explained by different socioeconomic position, education or lifestyle is still questionable [7,8].
A total of 475 patients on ART were included (53% male, median age 47 years, median duration of HIV infection 11.5 years) of whom 349 from hospital 1 and 126 from hospital 2. Overall, 315 (66%) participants were not born in France, of whom 231 (73%) were born in SSA, 18 (6%) in an European country, and 66 (21%) in another foreign country. All PLHIV have been on ART for at least 6 months; median duration on ART was 9.7 years (IQR, 4.5–16.2) with only 18 (3.8%) individuals on ART for less than one year. Patients’ characteristics according to the hospital are described in Table 1. More patients were born in a country from SSA in hospital 1 while more patients were men who have sex with men (MSM) or have been infected through intravenous drug use (IDU) in hospital 2. Among the whole population, median (IQR) EPICES score was 47.9 (29.0–63.9) and 74% could be classified as deprived. Deprivation was more frequent in hospital 1 (77%) than in hospital 2 (63%) (p = 0.003), in women (84%) and in non MSM men (73%) than in MSM (43%) (p<0.0001), and more frequent in migrants from SSA (87%) or from other foreign country (81%) than in PLHIV born in France (51%) (p<0.0001). Compared to non-deprived patients, deprived patients were slightly younger (median age, 47 vs 50 years, p = 0.01), less educated (39% with educational level lower than secondary school vs 17%, p<0.0001) and less employed (52% employed vs 68%, p = 0.003). There were no differences in duration of HIV infection, previous AIDS, CD4 nadir, ART duration or ART combination. In this cross-sectional study performed in a high income country with universal free access to HIV care and ART, deprivation was a major determinant of virological non-suppression on long term ART with VL>50 copies/ml in 17% of deprived patients and 5% of non-deprived patients. When using separate components of the EPICES score, reporting economic difficulties was associated with virological non-suppression. Other adjusted risk factors were reporting ART tiredness, younger age, and a previous AIDS event, but not migration in itself.
In our study that included PLHIV who had been on ART for a median duration of nearly 10 years, HIV viral load was undetectable (<50 copies/ml) in 86.5% of them at the time of the survey close to the challenge of the final UNAIDS 90-90-90 targets (i.e. 90% of HIV-infected people diagnosed, 90% of HIV-positive people on ART, 90% of people on ART with suppressed VL) which aims to end the HIV/AIDS epidemic. However, in a context of free universal access to care, deprivation and especially reporting financial difficulties are still risk factors for virological non-suppression. All barriers preventing long-term uninterrupted suppressed HIV VL should be identified and considered by health-care providers. In addition to interventions focusing on cultural aspects of migration aimed at increasing HIV diagnosis and linkage to care in specific HIV infected key population, social interventions are needed to help people with social vulnerability to obtain sustained responses on ART. Source: http://doi.org/10.1371/journal.pone.0213019