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

Abstract

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.

Socio-economic condition and lack of virological suppression among adults and adolescents receiving antiretroviral therapy in Ethiopia

“…Detectable VL was more common among ART recipients in the United Kingdom with unstable housing, non-university education, unemployment and financial hardship [15]. Other social and structural factors, such as homelessness, injection drug use and lack of social support, have also been associated with viremia during ART [16,17].…”

“…Lack of virological suppression during ART has been associated with advanced immunosuppression, high baseline viral load, longer ART duration, younger age and male gender [8][9][10][11][12][13]. Failure to achieve virological suppression has also been linked to various socio-demographic factors, including unstable housing, low educational status, unemployment and lack of financial or social support [14][15][16][17]. These factors have been associated with disease outcomes in a range of both communicable and non-communicable conditions, and are considered as important determinants of health [18].…”

Influence of Material Deprivation on Clinical Outcomes Among People Living with HIV in High-Income Countries: A Systematic Review and Meta-analysis

“…Poverty and deprivation are reported as fundamentally neighbourhood or area level factors and based on contextspecific measurement tools, including the Evaluation of Deprivation and Inequalities in Health Examination Centres (EPICES). Two of nine studies reported a significant adjusted negative association with virological suppression and deprivation [95,115]. For instance, Raho-Moussa et al [115] found that individuals who reported either individual determinants of deprivation (specifically financial difficulties in past month) or had an EPICES score indicating residence in a deprived state were 66% (aOR 0.34; 95% CI 0.16, 0.72) and 65% (aOR 0.35; 95% CI 0.14, 0.85) less likely, respectively, to achieve a VL < 50 copies/mL, compared to people living with HIV who did not meet these measures of deprivation, after adjusting for age and medication-, and clinically-related factors.…”

“…Two of nine studies reported a significant adjusted negative association with virological suppression and deprivation [95,115]. For instance, Raho-Moussa et al [115] found that individuals who reported either individual determinants of deprivation (specifically financial difficulties in past month) or had an EPICES score indicating residence in a deprived state were 66% (aOR 0.34; 95% CI 0.16, 0.72) and 65% (aOR 0.35; 95% CI 0.14, 0.85) less likely, respectively, to achieve a VL < 50 copies/mL, compared to people living with HIV who did not meet these measures of deprivation, after adjusting for age and medication-, and clinically-related factors. Only one study reported a significant adjusted association with medication adherence which was in a negative direction [63].…”

Living conditions, HIV and gender affirmation care pathways of transgender people living with HIV in France: a nationwide, comprehensive, cross-sectional, community-based research protocol (ANRS Trans&HIV)

“…Migrant people or people with social vulnerability respond less well to ART. 35 A survey analysing the Bichat hospital's HIV care unit database in 2015 showed that transgender people were more exposed to HIV and other sexually transmitted infections (STI) than other populations, and that their dermatological complications needed better management. 36 A second survey in the same care unit, which aimed to highlight the dangers associated with the clandestine use of cosmetic surgery, reinforced these results and showed that transgender women also presented physical health risks related to the illicit use of silicone.…”