Social inequalities associated with late HIV diagnosis and delayed HIV treatment – European study

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Even in the context of western European countries with universal access to health care, there are socioeconomic inequalities in timely access to HIV testing, according to a study published online ahead of print in AIDS. People with lower levels of education are more likely to be diagnosed with advanced HIV disease and to start HIV treatment with a low CD4 cell count.

“Policies and interventions that target socioeconomic determinants leading to delays in HIV diagnosis and ART (antiretroviral therapy) initiation are needed,” argue the authors.

It is well known that lower socioeconomic status is associated with less use of health services in the general population, even when health care is widely and freely available. Since the HIV epidemic is entrenched among socially vulnerable groups, including men who have sex with men, people who inject drugs and migrants – including undocumented migrants – questions about the effect of socioeconomic status on the diagnosis and treatment of people living with HIV should be a particular concern. But little HIV-focused research has been published on the topic.


advanced HIV

A modern term that is often preferred to 'AIDS'. The World Health Organization criteria for advanced HIV disease is a CD4 cell count below 200 or symptoms of stage 3 or 4 in adults and adolescents. All HIV-positive children younger than five years of age are considered to have advanced HIV disease.

statistical significance

Statistical tests are used to judge whether the results of a study could be due to chance and would not be confirmed if the study was repeated. If result is probably not due to chance, the results are ‘statistically significant’. 

observational study

A study design in which patients receive routine clinical care and researchers record the outcome. Observational studies can provide useful information but are considered less reliable than experimental studies such as randomised controlled trials. Some examples of observational studies are cohort studies and case-control studies.


The study of the causes of a disease, its distribution within a population, and measures for control and prevention. Epidemiology focuses on groups rather than individuals.

risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.

Sara Lodi and colleagues therefore analysed cohort data from six countries in the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE). Data were included from 15,414 people who were diagnosed in Austria, France, Greece, Italy, Spain or Switzerland between 1996 and 2011.

The researchers were interested in the following outcomes: being diagnosed with late HIV disease (CD4 below 350 cells/mm3); being diagnosed with advanced HIV disease (CD4 below 200 cells/mm3); and starting HIV treatment late (CD4 below 350 cells/mm3).

As a proxy measure of socioeconomic status, the researchers used educational level. While this is somewhat incomplete as a measure, it was the only indicator that was collected in several European countries in a standardised way. Moreover, there are methodological difficulties with other measures such as annual income and social class.

Individuals’ level of completed education was classified as:

  • Uncompleted basic;
  • Basic (primary and lower-secondary schooling);
  • Secondary (generally, schooling over the age of 16);
  • Tertiary (university or vocational courses).

Across the cohorts, 62% of people were diagnosed late, with a CD4 count of 350 cells /mm3 or below. However, late diagnosis was much more common among people with uncompleted basic (73%) or basic (65%) education than among those with secondary (59%) or tertiary (55%) education.

Similarly 40% of people were diagnosed with advanced HIV disease, with a CD4 count below 200 cells /mm3, but this also varied by educational level – 52% of people with uncompleted basic, 45% with basic, 37% with secondary and 31% with tertiary education were diagnosed very late.

The differences in outcomes were statistically significant when analysed in multivariate models that took account of other factors known to affect late diagnosis (p < 0.001).

Education had a greater impact on outcomes in men than women, with this being especially true for men who have sex with men.

Inequalities have also become more pronounced in recent years, and were especially noticeable in Greece, Italy and Spain.

In terms of the CD4 cell count at which people began HIV treatment, this was 173 for people with uncompleted basic education, 198 with basic education, 238 with secondary and 251 with tertiary education (p < 0.001).

This was largely but not exclusively driven by the trends in late diagnosis – people who have been diagnosed late will almost inevitably start treatment late. In an analysis only of people who had not been diagnosed very late, there was a trend for people with less education to start treatment later, but this wasn’t statistically significant.

The authors suggest a number of potential explanations for the inequalities they have identified.

  • Education is a proxy for socioeconomic status more generally. Individuals with greater education have better employment, salaries and material resources, which imply easier access to healthcare facilities.
  • People with more education are more likely to practise healthy behaviours, including regular health checks and HIV testing following risk behaviour.
  • Education increases people’s health literacy and cognitive skills, enabling them to make better informed health-related choices, including decisions about HIV testing and the timely initiation of antiretroviral therapy.
  • Education is linked with social and psychological factors, including sense of control, social standing and social support; individuals with more education may face fewer barriers to access HIV care and be more resilient to stigma.

The authors suggest that inequalities in access to and use of HIV testing services in particular need to be tackled.

“This study shows that inequalities by educational level, a proxy of a socioeconomic status, in HIV testing and initiation of cART [combination antiretroviral therapy] are present in European countries with universal healthcare systems,” they conclude. “Thus, individuals with lower educational level will not equally benefit from the effectiveness of cART”.


Lodi S et al. Delayed HIV diagnosis and initiation of antiretroviral therapy: inequalities by educational level, COHERE in EuroCoord AIDS, 2014. doi: 10.1097/QAD.0000000000000410