Mortality is influenced by locality in a major HIV/AIDS epidemic

Abstract

Objectives The aim of the study was to compare the risks of death among HIV‐infected patients on highly active antiretroviral therapy (HAART) in two proximate, yet distinct neighbourhoods: a neighbourhood with a high concentration of gay men, and a neighbourhood with a high concentration of injecting drug users. Methods We compared the clinical and socioeconomic characteristics of HIV‐infected patients from the two neighbourhoods entering the British Columbia Centre for Excellence in HIV/AIDS Drug Treatment Program from 1 September 1997 to 30 November 2005, using contingency table statistics. Cox survival models and Kaplan–Meier methods were used to estimate the cumulative mortality rates. Results We found significant differences between patients from the two neighbourhoods for all socioeconomic variables. Patients in the neighbourhood with a high concentration of injecting drug users were more likely to be female, have a history of injecting drug use, have a less HIV‐experienced physician and be less adherent. Patients in the neighbourhood with a high concentration of gay men were more likely to have AIDS. Mortality was significantly higher for patients in the neighbourhood with a high concentration of injecting drug users [hazard ratio (HR) 3.01; 95% confidence interval (CI) 1.73, 5.24]. Conclusions A threefold increase was observed in the risk of death among HIV‐infected individuals on HAART in the neighbourhood with a high concentration of injecting drug users relative to the neighbourhood with a high concentration of gay men. The implications of this study should be assessed in similar HIV/AIDS epicentres.

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

“…Low household income was a significant predictor of mortality among patients with HIV/AIDS in three Canadian studies, a setting with universal access to health care [75,83,86]. However, one study with individually collected SES data did not find an association between income and HIV/AIDS mortality risk [77].…”

“…Four studies examined effects of SES on mortality with HIV/AIDS in the years of pre-HAART period [70][71][72][73]. Fifteen studies provided an assessment of SES in relation to survival in HIV-infected patients during the years of commercial availability of HAART [74][75][76][77][78][79][80][81][82][83][84][85][86][87][88]. Two studies [34,35] evaluated the impact of SES on survival with HIV/AIDS in both periods.…”

“…Five studies carried out in different countries indicated that education beyond a high school degree was a statistically significant protective factor for all-cause and HIV/AIDS-related mortality [77,78,82,83,86], and one report showed no significant association with education [87]. Poverty as the area-level SES factor was positively associated with an increased risk of death in HIV-infected patients even after adjustments for age, clinical and treatment variables [83,84].…”

“…The only study that examined the effect of social context on survival of HIVinfected children found that maternal unemployment was associated with lower survival after adjustment for baseline AIDS diagnosis [78]. Lack of employment, an important dimension of maternal, social, and human capital, was found to be associated with an increased risk for HIV/AIDS mortality in four other studies applying this measure after adjusting for demographic, clinical and treatments factors [77,81,83,86].…”

“…Included in the review, 15 reports of post-HAART period examined relationships between SES and all-cause mortality and HIV/ AIDS-related mortality among HIV-infected patients with the mean age ranging from 11 to 42.5 years and the median follow-up ranging from 12 months to 8.6 years [74][75][76][77][78][79][80][81][82][83][84][85][86][87][88]. The composite index of one of these studies was based on the variables of availability of stable income, owned residential property, the need to receive social support, and the effective availability of this support in the past and at the time of interview [82].…”