Gender inequalities in the response to combination antiretroviral therapy over time: the Swiss HIV Cohort Study

Abstract

ObjectivesGender-specific data on the outcome of combination antiretroviral therapy (cART) are a subject of controversy. We aimed to compare treatment responses between genders in a setting of equal access to cART over a 14-year period. MethodsAnalyses included treatment-naïve participants in the Swiss HIV Cohort Study starting cART between 1998 and 2011 and were restricted to patients infected by heterosexual contacts or injecting drug use, excluding men who have sex with men. ResultsA total of 3925 patients (1984 men and 1941 women) were included in the analysis. Women were younger and had higher CD4 cell counts and lower HIV RNA at baseline than men. Women were less likely to achieve virological suppression < 50 HIV-1 RNA copies/mL at 1 year (75.2% versus 78.1% of men; P = 0.029) and at 2 years (77.5% versus 81.1%, respectively; P = 0.008), whereas no difference between sexes was observed at 5 years (81.3% versus 80.5%, respectively; P = 0.635). The probability of virological suppression increased in both genders over time (test for trend, P < 0.001). The median increase in CD4 cell count at 1, 2 and 5 years was generally higher in women during the whole study period, but it gradually improved over time in both sexes (P < 0.001). Women also were more likely to switch or stop treatment during the first year of cART, and stops were only partly driven by pregnancy. In multivariate analysis, after adjustment for sociodemographic factors, HIV-related factors, cART and calendar period, female gender was no longer associated with lower odds of virological suppression. ConclusionsGender inequalities in the response to cART are mainly explained by the different prevalence of socioeconomic characteristics in women compared with men.

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

“…In previous European studies11, 12, 13, 14 of socioeconomic status and ART outcomes in which education level was used as the sole indicator of socioeconomic status, lower education level was associated with virological non-suppression in two of three studies. Two additional European studies considered employment status and noted that unemployment was associated with twice the adjusted risk of virological failure 15 and that viral load of more than 50 copies per mL was associated with twice the unadjusted odds of developing inability to work among those able to work when starting ART 25 .…”

“…Therefore, the associations between socioeconomic factors and HIV outcomes in the USA might not be generalisable to settings with free universal health care, which have been little studied 11 . Findings of two large European studies, the Swiss HIV Cohort study 12 and the Spanish CoRIS study, 13 showed that lower education level was associated with increased odds of viral load being higher than 50 copies per mL at 12 months after ART initiation (unadjusted odds ratios of 1·3 and 1·9, respectively); however, the Danish HIV Cohort study 14 noted no clear association. Additionally, in the Italian ICoNA cohort study 15 in individuals who had been taking ART for at least 6 months, unemployment was associated with double the risk of virological failure compared with working full-time.…”

Out of focus: tailoring the cascade of care to the needs of women living with HIV

“…A meta-analysis of clinical studies, assessing ART over a period of at least 48 weeks between 2000 and 2008, found several significant gender-related differences favouring better efficacy in men than in women [53]. The Swiss HIV Cohort study reported on outcomes in 3925 patients, of whom 1941 were women, with access to combination ART over a 14-year period (1998-2011) [22]. Prior to starting ART, women in this cohort study were younger and had higher CD4 cell counts and lower viral loads than men.…”

“…Gender-specific factors can also impact on the clinical care of WLWH post-diagnosisaffecting access to and retention in care, management, and the likelihood of achieving and maintaining viral suppression on ART (Table 1) [12,[17][18][19][20][21][22]. In addition to female-specific challenges around reproductive considerations, pregnancy and menopause, women differ from men in body composition and pharmacokinetic (PK) parameters.…”

“…In this new era, HIV management is undergoing a paradigm shift, with increased emphasis on prevention, and a focus on optimizing the cascade of HIV care and [3]. Table 1 Potential impact of gender in HIV infection [12,[17][18][19][20][21][22] the long-term wellbeing of PLWH [23]. Increased efforts and specific considerations are required to address the additional health issues associated with the unique factors, comorbidities, and ageing-related issues that WLWH face today [24,25].…”