Socioeconomic position and ten-year survival and virologic outcomes in a Ugandan HIV cohort receiving antiretroviral therapy

<div><p>Lifelong ART is essential to reducing HIV mortality and ending the epidemic, however the interplay between socioeconomic position and long-term outcomes of HIV-infected persons receiving antiretroviral therapy (ART) in sub-Saharan Africa is unknown. Furthering the understanding of factors related to long-term ART outcomes in this important region will aid the successful scale-up of ART programs. We enrolled 559 HIV-infected Ugandan adults starting ART in 2004–2005 at the Infectious Diseases Institute in Kampala, Uganda and followed them for 10 years. We documented baseline employment status, regular household income, education level, housing description, physical ability, and CD4 count. Viral load was measured every six months. Proportional hazard regression tested for associations between baseline characteristics and 1) mortality, 2) virologic failure, and 3) mortality or virologic failure as a composite outcome. Over ten years 23% (n = 127) of participants died, 6% (n = 31) were lost-to-follow-up and 23% (107/472) experienced virologic treatment failure. In Kaplan-Meier analysis we observed an association between employment and mortality, with the highest cumulative probability of death occurring in unemployed individuals. In univariate analysis unemployment and disease severity were associated with mortality, but in multivariable analysis the only association with mortality was disease severity. We observed an association between higher household income and an increased incidence of both virologic failure and the combined outcome, and an association between self-employment and lower incidence of virologic failure and the combined outcome when compared to unemployment. Formal education level and housing status were unrelated to outcomes. It is feasible to achieve good ten-year survival, retention-in-care, and viral suppression in a socioeconomically diverse population in a resource-limited setting. Unemployment appears to be related to adverse 10-year ART outcomes. A low level of formal education does not appear to be a barrier to successful long-term ART.</p></div

Death or virologic failure among HIV-infected participants surviving more than six months on ART grouped by household income and by participant employment status (N = 472).

<p>Caption: Fig 1A shows a trend towards increased risk of death and viral failure among participants with higher regular household income, while Fig 1B shows a trend towards decreased risk of death and viral failure among self-employed and privately employed participants. The multivariable proportional hazard regression identified a significant positive association between higher household income and higher incidence of the composite outcome and a significant association between self-employment and decreased incidence of the composit outcome compared with unemployment.</p

Cohort descriptive characteristics.

<p>Cohort descriptive characteristics.</p

Risk factors for 10-year mortality or virologic failure (combined outcome) in a Ugandan cohort with baseline AIDS receiving ART (N = 472).

<p>Risk factors for 10-year mortality or virologic failure (combined outcome) in a Ugandan cohort with baseline AIDS receiving ART (N = 472).</p