People with HIV who have lower educational attainment have poorer outcomes after starting
combination antiretroviral therapy (cART), according to data from a large
European cohort collaboration published in the online edition of AIDS. Rates of mortality and AIDS
decreased with increasing education level, and education was also associated
with virological suppression and CD4 count at the time of cART initiation.
differences in mortality and clinical responses to cART could not be explained
entirely by delayed HIV diagnosis or late cART initiation, since differences
largely remained after we restricted analyses to those initiating cART with CD4
> 350 cells/mm3 and without previous AIDS diagnoses,” comment the
authors. “The associations we found between educational level and clinical
outcomes are probably mediated by material and psychosocial paths.”
Even in countries
with free access to healthcare, lower socioeconomic group is associated with
poorer health outcomes. Investigators from a large collaboration of HIV cohort
studies – the Collaboration of Observational HIV Epidemiological Research in
Europe (COHERE) – have already shown that late diagnosis of HIV and starting
cART with a low CD4 count are associated with lower levels of education. The researchers
now wanted to see if disparities in health outcomes by education persisted
after cART initiation.
They therefore designed
a study examining differences by educational level in mortality and new AIDS
after starting cART and also viral suppression and CD4 count changes.
Data from 15
cohort studies in eight countries were available for analysis. Adult patients
starting cART for the first time between 1996 and 2013 were eligible for
inclusion. Educational level was standardised across the cohorts.
The main outcomes
- All cause mortality.
- New AIDS event or death.
- Virological suppression – two
successive viral load measurements below 400 copies/ml.
- CD4 cell increases during the
first six years of cART.
adjusted to take account of sex, age at cART initiation, calendar period of
cART initiation (before 2001; 2001-04; 2005-08; 2009-13), transmission
category, pre-cART viral load and CD4 count; pre-cART AIDS and type of cART.
A total of 24,069
people were eligible for inclusion. Overall, 9% had not completed primary
education; 32% had only a primary education; 44% had completed secondary
education and 14% had a college education or equivalent.
Individuals with a
secondary and college education were more likely to be male and in the
men-who-have-sex-with-men transmission category. A fifth of women were in the
lower educational strata.
There was an
association between education and mortality. During 132,507 person-years of
analysis, 1081 people died. Mortality decreased as educational level
increased (p < 0.001) and these differences persisted in models that
adjusted for potential confounders. People with a college education had a
lower risk of death than all other educational groups. A similar mortality
pattern was present in an analysis controlling for CD4 count at the time of
cART initiation, previous AIDS and age at the time treatment was started.
A significant association
was also present between education and mortality and AIDS. Over 122,765
person-years, there were 2598 new AIDS events or deaths. Differences in
incidence of AIDS/death by educational level were even more marked than for
death alone (p < 0.001).
One year after
starting HIV therapy, 77% of patients had attained viral suppression. This was
achieved by 67% of people with incomplete primary education, 85% of
individuals with a primary education, 82% of individuals with a secondary
education and 87% of individuals who had attended college (p < 0.001).
Differences in outcomes between the groups became less pronounced over time and
ceased to be significant after ten years of therapy. After adjusting for
possible confounders, those with an incomplete primary education or a primary
education only had 20% and 7% lower chances, respectively, of attaining a
virological response than patients who attended college.
immunological outcomes, the data showed that the higher the educational
level achieved, the higher the CD4 count at cART initiation. However, there was no
evidence that educational level was associated with CD4 count recovery six
months after starting therapy.
“HIV-positive patients on combination
antiretroviral therapy who had less education had higher mortality, higher
rates of new AIDS, and worse virological responses than patients under care who
had more education,” write the authors. “We observed such health differentials
for an eighteen-year period in eight European countries where access to health
care and cART is universal.”