Living with HIV in France in the 21st century: Employment, response to treatment, and quality of life

Several reports from a large French study, published in a supplement to the January 2^nd edition of AIDS, provide more evidence that HIV-related health is strongly dependent on social and economic factors, that immigrants are at heightened risk of treatment failure, and that managing HIV infection while at work remains a challenge.

The VESPA Study

The VESPA Study is a large-scale study of the social and living conditions of people with HIV in France. In France, access to care for HIV infection is universal, and almost entirely managed through hospital outpatient clinics. For the VESPA Study, nearly 3,000 adults (at least 18 years old, HIV-positive for at least six months) were recruited from 102 hospital clinics between December 2002 and September 2003.

A few caveats apply to the VESPA Study as a whole. Participation was voluntary, and not completely representative. People who had lived in France less than six months, and those with “a very poor understanding of the French language” were excluded. Out of 4,963 eligible individuals randomly selected to participate, 1,767 declined, and 264 were screened out due to “major cognitive impairment or health problems”, leaving an overall number of 2,932 participants (59% of the original sample).

The resultant participating sample differed from the overall HIV-positive French population in many ways. The investigators addressed these biases by weighting the responses so that the weighted sample was comparable to the overall HIV-positive population in route of infection (heterosexual, male/male, injection drug use [IDU]), employment status and immunological status.

Secondly, VESPA was a retrospective, cross-sectional study, without prospective follow-up. However, the investigators note that this design might have been better at representing “individuals with the most precarious socioeconomic conditions” – precisely those of particular interest.

Here, we report on three reports from the VESPA Study published in a 2007 supplement to the journal AIDS, regarding response to therapy, quality of life, and employment.

Response to antiretroviral treatment

Not everyone benefits fully from antiretroviral therapy, even in developed countries. Studies have shown that social, economic and cultural differences play at least as big a role as medical factors: the poorest people, injection drug users (IDUs), and immigrants are less likely to do as well on treatment. This is confirmed by this substudy of the French VESPA Study.

Investigators looked the 896 VESPA participants who had been on their first antiretroviral regimen for at least six months at the time of the study. These were broken down into seven groups according to route of infection and country of origin:

 

• (38.4%) men – gay/bisexual
• (16.9%) men – heterosexual – non-IDU – French-born
• (11.0%) men – heterosexual – non-IDU – immigrant
• ( 8.7%) men – heterosexual – IDU
• (10.4%) women – non-IDU – French-born
• (11.3%) women – non-IDU – immigrant
• ( 3.3%) women – IDU

 

Most of the immigrants - 76% of the men and 82% of the women - were from sub-Saharan Africa, but these countries of origin were not specifically split out in the analysis. These groups were then compared according to three types of “treatment failure”:

 

• “Immunologic” failure (IF): if CD4 cells did not increase by 100 cells/mm³ between starting treatment and the time of the study.
• “Immunovirologic” failure (IVF): having a detectable viral load and fewer than 200 CD4 cells/mm³ at the time of the study.
• “Clinical” failure (CF): having an AIDS-defining illness after more than three months on treatment.

 

Note the somewhat curious definition of “immunovirologic” failure, rather than the simpler “virologic” failure – having a detectable viral load – as used in most clinical trials.

Overall, 19.6% of the group experienced immunologic failure (IF), 3.4% immunovirologic failure (IVF), and 3.0% clinical failure (CF). These failure rates were very different across the subgroups; the best responses were most often seen in gay/bisexual men. Multivariate analysis identified the following as the likeliest risk factors for treatment failure (p < 0.05):

 

• For IF: being an immigrant, being on anti-HIV therapy for less than 24 months, poor adherence, and hepatitis C co-infection.
• For IVF: being an immigrant, starting anti-HIV therapy with CD4 cell count ≤ 50 cells/mm³, and current drug use.
• For CF: being an immigrant male, being 50 years old or older, starting anti-HIV therapy with CD4 cell count ≤ 200 cells/mm³, or a history of interruption in care.

 

Overall, while risk factors varied for the various types of treatment failure, treatment-naive immigrants were more likely to “fail” by any definition, all other things being equal. This is consistent with a recent study from the Netherlands (Nellen 2004); two other studies (Jensen-Fangel 2002, Smith 2004) did not find that immigrants fared worse, but these studies also included treatment-experienced people.

The researchers could only speculate as to reasons. Since other studies have found that race itself is not a medical factor in treatment failure (Frater 2002, Anastos 2005), the researchers suggest that the differences “result from differences in living conditions… adverse socioeconomic conditions… precarious housing… financial difficulties … food privation through lack of money… social isolation… and healthcare providers’ attitudes and interactions with their patients.” In other words, these people might be faring poorly not because they are immigrants per se, but because they are poor and have difficult lives.

Quality of life

Clinicians and researchers recognize that the goal of therapy is not limited to CD4 cell counts, viral load, and clinical outcomes, but rather, overall quality of life. In France’s first nationwide picture of health-related quality of life (HRQL) for people with HIV, a report from the VESPA Study found that only about half of the people interviewed had “acceptable” HRQL scores.

Researchers asked the 2,235 participants from the VESPA Study to complete two self-report questionnaires: the Medical Outcome Study 36-Item Short Form Health Survey (MOS SF-36) and the Hospital Anxiety and Depression (HAD) scale. Responses were gathered from 2,235 individuals: 80% on anti-HIV therapy and 20% not on antiretrovirals, or on “non-HAART” treatment. Given that people “facing the worst conditions” are the least likely to participate, selection bias was taken into account: researchers felt that “such a bias was not found[,] suggesting quite a high degree of validity”.

People were rated as having an “acceptable” physical and mental HRQL if their MOS SF-36 score was in at least the 25 percentile of comparable scores from the general population. (i.e., “acceptable” meant scoring no worse than 25% of the same sex and age bracket of France’s overall population.) Even by this undemanding definition, only 52.6% and 51.5% of the participants had an “acceptable” physical and mental HRQL, respectively.

The following were risk factors for both lower physical and mental HRQL (by multivariate analysis, p < 0.02): financial hardship, adverse treatment reactions, disclosure of HIV status (to family or at work), high anxiety/depression, and the use of psychoactive drugs. For low physical HRQL, being younger than 47, poor housing, AIDS-defining events, detectable viral load and rejection by medical staff were also risk factors. Low CD4 cell count and discrimination due to HIV status were also risk factors for low mental HRQL only (p< 0 .007).

It should be no surprise that poor HRQL is seen in the poor and poorly housed. Stigma and rejection also adversely affect health, as shown in previous studies. Although analysis identified drug use as a factor, the report notes that “HRQL is determined more by mental health problems than drug dependence or history per se.” Similarly, hepatitis C co-infection “appears not to be directly associated… as reported by others, but instead… appears like a marker of low social conditions”.

The association of disclosure with worse status was interesting: it was suggested that this could either mean that sicker people were less able to conceal their HIV status, or (conversely) that disclosure, especially forced disclosure, resulted in discrimination and hence worsened HRQL.

The researchers “suggest that HAART is not able to restore an acceptable [health-related quality of life] in significant portions of the population… living with HIV.”

Living and working with HIV

Unemployment is high among HIV-positive people in western countries (reports range between 45 and 65%), yet unemployment is tied to worsened health both in people with HIV and the general population. Investigators used VESPA Study data and face-to-face questionnaires on employment status to characterise work status for HIV-positive people in France in 2003.

Of the 2,932 VESPA participants, 2,750 were under age 60 and thus generally eligible to be in the workforce in France. Employment information was available for all these people; self-reported health status (excellent, very good, good, fair, poor) was available for 2,183.

Overall, 56.5% of the 2,750 work study participants were employed: 44.9% had remained employed ever since diagnosis, and 11.6% had been employed at some time since diagnosis. Those who were employed (at any time since HIV diagnosis) were more likely (p ≤ 0.05) to: have been diagnosed in 1996 or later, rate their health as good or better, never have been hospitalised, be a heterosexual immigrant, be younger than 30, to be more educated (college or better), and not to be a single parent.

Of the 1,207 unemployed, 64.5% planned to return to work. Those who planned to return were more likely (p≤0.05) to: have been diagnosed in 2000 or later, be a heterosexual immigrant male, be younger than 50, have a higher education, to be a single parent, and not to be receiving disability benefits.

Most (70.1%) of the working respondents had not disclosed their HIV status at work. Of those who had disclosed, only 12.1% reported HIV-related discrimination. Only 8.5% reported any accommodation of their HIV status at work – reduced work demands or hours, or a switch to another position.

The researchers “suggest that working while being infected with HIV remains a difficult challenge”. Barriers to work (or return to work) include physical health limitations, reluctance to disclose, discrimination (actual, feared, or anticipated), and disability benefits that can, in some cases, form more of a “poverty trap” than safety net. “Assisting people with HIV in accessing employment or keeping their jobs” should remain a key policy goal.