Socioeconomic Status, Access to Triple Therapy, and Survival From HIV-Disease Since 1996
February 10, 2003
Since the introduction of HAART in 1996, antiretroviral therapy has decreased viral load, improved CD4 cell counts, and led to declines in HIV-related morbidity and mortality. Before HAART, lower socioeconomic status was associated with shorter survival time after HIV infection. The current study examines socioeconomic status, access to HAART, and mortality in the context of a universal health care system.Adapted from:
The researchers evaluated 1,408 individuals in British Columbia who began double or triple therapy between August 1, 1996 and December 31, 1999 and followed them until March 31, 2000. British Columbia distributes HIV medication at no cost to HIV-infected patients through the BC Center for Excellence in HIV/AIDS Drug Treatment Program. Antiretroviral therapy-naive patients with plasma viral loads greater than 100,000 copies/ml were offered triple drug regimens; those with viral loads from 5,000 to 100,000 copies/ml were offered dual nucleoside therapy. In July 1997, the center's therapeutic guidelines were revised to recommend triple combination therapy for all antiretroviral-naive individuals with plasma viral loads of 5,000 copies/ml or greater or a CD4 cell count below 500 cells/mm3. General practitioners enroll eligible participants in the program on submission of a prescription for antiretroviral or approved antimicrobial medications. Less than 1 percent of HIV-infected British Columbians purchase antiretroviral therapy outside the program.
In this study, the authors assessed socioeconomic status by linking participants to Canadian census-based socioeconomic data through their postal code, using the patients' neighborhoods' median income as a marker. They defined low socioeconomic status as the government's low-income cutoff of Canadian $14,147. Those who lived in a neighborhood with an individual median income above that amount were classified as having high socioeconomic status.
Of the 1,408 patients studied, 27 percent were initially prescribed a double drug combination, and 73 percent were initially prescribed a triple combination with either a PI or a NNRTI. Data analyses showed statistically significant differences in survival between those in the high and low socioeconomic strata. Patients of low socioeconomic status who received double therapy were significantly more likely to die than patients in either socioeconomic strata who received triple therapy as their initial regimen.
"In the present study we found that individuals of lower socioeconomic status were substantially less likely to receive triple combination therapy as their initial regimen ...," the report states. "In addition, we identified lower socioeconomic status to be independently associated with mortality among patients receiving antiretroviral treatments since 1996. Interestingly, the association between socioeconomic status and survival did not persist in analyses ... stratified by double or triple therapy, or when analyses were restricted to individuals who received triple combination therapy as their initial regimen."
The authors found that people of lower socioeconomic status and with a history of injection drug use were less likely to be prescribed HAART, which "may reflect the concerns of physicians who hoped that individuals with less stable lifestyles may have better adherence to a less complex regimen." They also speculated that concerns about the possible transmission of a PI- or NNRTI-resistant virus influenced the doctors' decisions.
"In a population-based setting in which antiretroviral drugs are delivered free of charge through a universal healthcare system," the authors concluded, "there is evidence that lower socioeconomic status is associated with shorter survival. Our analyses indicate that the association between socioeconomic status and survival may be confounded by inequitable access to triple therapy according to socioeconomic status. This finding suggests that further efforts must be focused on increasing the awareness, implementation, and monitoring of therapeutic guidelines to ensure that physicians treating HIV-positive patients deliver care in accordance with the most recent evidence-based approaches."
10.18.02; Vol. 16: P. 2065-2072; Evan Wood; Julio S.G. Montaner; Keith Chan; Mark W. Tyndall; Martin T. Schechter; David Bangsberg; Michael V. O'Shaughnessy; Robert S. Hogg
This article was provided by CDC National Prevention Information Network. It is a part of the publication CDC HIV/Hepatitis/STD/TB Prevention News Update.