Socioeconomic inequalities in access to HIV care in European countries with universal healthcare systems

Delayed HIV diagnosis and initiation of antiretroviral therapy: inequalities by educational level, COHERE in EuroCoord.

Socio-economic Inequalities and HIV Writing Group for Collaboration of Observational HIV Epidemiological Research in Europe (COHERE) in EuroCoord. AIDS. 2014 Sep 24;28(15):2297-306. doi: 10.1097/QAD.0000000000000410.

Objectives: In Europe and elsewhere, health inequalities among HIV-positive individuals are of concern. We investigated late HIV diagnosis and late initiation of combination antiretroviral therapy (cART) by educational level, a proxy of socioeconomic position.

Design and Methods: We used data from nine HIV cohorts within COHERE in Austria, France, Greece, Italy, Spain and Switzerland, collecting data on level of education in categories of the UNESCO/International Standard Classification of Education standard classification: non-completed basic, basic, secondary and tertiary education. We included individuals diagnosed with HIV between 1996 and 2011, aged at least 16 years, with known educational level and at least one CD4 cell count within 6 months of HIV diagnosis. We examined trends by education level in presentation with advanced HIV disease (AHD) (CD4 <200 cells/µl or AIDS within 6 months) using logistic regression, and distribution of CD4 cell count at cART initiation overall and among presenters without AHD using median regression.

Results: Among 15 414 individuals, 52, 45, 37, and 31% with uncompleted basic, basic, secondary and tertiary education, respectively, presented with AHD (P trend <0.001). Compared to patients with tertiary education, adjusted odds ratios of AHD were 1.72 (95% confidence interval 1.48-2.00) for uncompleted basic, 1.39 (1.24-1.56) for basic and 1.20 (1.08-1.34) for secondary education (P < 0.001). In unadjusted and adjusted analyses, median CD4 cell count at cART initiation was lower with poorer educational level.

Conclusions: Socioeconomic inequalities in delayed HIV diagnosis and initiation of cART are present in European countries with universal healthcare systems and individuals with lower educational level do not equally benefit from timely cART initiation.

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Editor’s notes: COHERE in EuroCoord is a collaboration of 35 observational cohorts covering 32 European countries. The present study uses data from nine cohorts in six countries which collected data on educational achievement. Health inequalities are a growing concern in resource rich settings and this study confirms that even in Europe in the era of wide antiretroviral therapy (ART) use, individuals with lower educational attainment were more likely to present with advanced HIV disease. The association was stronger in men. This is possibly due to earlier diagnosis in women attending antenatal services who benefit from universal offer of HIV testing for prevention of mother-to-child transmission. People who were less educated were also more likely to initiate ART at a lower CD4 count. Interestingly, this latter association was seen even when analyses were restricted to individuals who were diagnosed early. This suggests lower education and by proxy socioeconomic status, is a further and specific barrier to ART initiation, even amongst individuals diagnosed in a timely fashion. The authors conclude that their findings suggest policies and activities that target socioeconomic determinants leading to delays in HIV diagnosis and combination antiretroviral therapy (cART) initiation are needed.

Health care delivery
Europe
Austria, France, Greece, Italy, Spain, Switzerland
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