A French study suggests that, even when effective anti-HIV treatments are available, HIV-positive individuals have a high risk of being hospitalised in the early years of HIV infection. The study, which is published in the October 1st edition of the Journal of Acquired Immune Deficiency Syndromes also revealed that adverse social and economic conditions, including the lack of a stable relationship and not having a permanent job were risk factors for hospitalisation or death in the few first years after infection with HIV.
“Health benefits of recent advances in HIV infection management have been shown to differ between groups of patients independent of their clinical characteristics”, write the investigators from the PRIMO cohort study. This cohort includes patients who were diagnosed with primary HIV infection. A total of 319 patients were recruited to the study between 1996 and 2002 and were included in the investigators’ current analysis.
The investigators noted that several earlier studies have suggested that some groups of patients, in particular ethnic minorities, drug users, women and younger patients do not seem to have benefited from HIV therapy as much as other groups.
The aim of the current study was to see if there was an independent association between social and economic factors and hospitalisation or death in the first few years of HIV infection. Access to HIV care is universal in France, and patients are treated as outpatients. Therefore the investigators believed that hospitalisation for any cause would be an indicator of declining health.
Follow-up was provided for a median of 2.5 years. Patients enrolled in the study were overwhelmingly male (83%), French or Europeans (90%), and had been infected with HIV through sex with another man (62%). The median age at enrolment was 33 years. At enrolment, 78% reported being in a permanent job and 61% said that they were in a stable relationship.
The investigators were aware that the design of their cohort meant that recruitment would be biased towards the most socially privileged patients with HIV in France. They observe, “to be enrolled in the PRIMO cohort, patients had to be diagnosed as infected with HIV in the early stages of primary infection and had to become involved in a long-term prospective follow-up, conditions that are likely to exclude the most socially fragile patients.”
Anti-HIV therapy was started in 68% on enrolment to the cohort, and after a year of follow-up 80% of patients were taking potent antiretroviral therapy.
There was a low rate of hepatitis B virus and hepatitis C virus coinfection at baseline (5%), respiratory disease was present in 3% on recruitment, at which time 2% had diabetes or high blood pressure and 2% a history of mental health problems.
A total of 84 individuals were hospitalised on a total of 109 occasions and three patients died. These events occurred a median or 1.1 year after diagnosis with the early stages of HIV infection.
Multivariate analysis indicated that two social factors were significantly associated with hospitalisation. These were being in temporary employment (p < 0.05), and not having a stable relationship (p < 0.05). The investigators also found that having a mental disorder or depression at baseline (p < 0.05), a history of injecting drug use (p < 0.05), a CD4 cell count below 200 cells/mm3 (p <0.05) and a viral load above 100,000 copies/ml (p < 0.05) were all significantly associated with an increased risk of hospitalisation or death.
HIV or a side-effect of antiretroviral therapy was estimated to be the cause of 25% of hospitalisations, 21% were due to mental disorders and the rest were attributed to other causes, mostly to non-HIV-related illness and surgery.
Tuberculosis, lymphoma and suicide were the causes of the three deaths.
“Social conditions are independently associated with patients’ health status,” comment the investigators. They suggest a number of ways in which poor social and economic conditions could damage health. Stress, they suggest, could directly damage the body’s defences against illness, or could increase risky behaviours such as smoking or drug- taking. Poor social and economic conditions could, the investigators suggest, also be a marker for poor support networks, and they believe that individuals in temporary employment may be more likely to work in environments which could damage health.
“In the era of HAART, the risk of hospitalisation is high from the first months of HIV disease”, the authors conclude.
Dray-Spira R et al. Temporary employment, absence of stable partnership, and risk of hospitalization or death during the course of HIV infection. J Acquir Immune Defic Syndr 40: 190 – 197, 2005.