People with HIV living in poorer areas of San Francisco are more likely to progress to AIDS than those living in wealthier districts, according to a study published in the May 1st edition of the Journal of Acquired Immune Deficiency Syndromes. However, the study also found that amongst patients who managed to access highly active antiretroviral therapy (HAART), there was no difference in survival regardless of wealth and social status.
The study adds to a growing body of research suggesting that socially disadvantaged patients are less likely to access HAART, with factors such as as poorer healthcare, lower levels of education, inadequate adherence, and higher levels of injecting drug use often to blame.
Investigators at the San Francisco public health department and Johns Hopkins University recorded the address for every patient known to have died of an HIV-related cause prior to the availability of HAART in 1996, and from 1996 to the end of 2001. The investigators then divided San Francisco into 22 districts according to average household income to see if they could establish any relationship between the prognosis of patients with AIDS and their social and economic status in both the pre- and post-HAART eras.
Data on HIV treatment history, age, sex, date of HIV diagnosis, CD4 cell count at time of HIV diagnosis were collected. The investigators also recorded if a patient was receiving care from a public or private healthcare facility.
Two epicentres of AIDS deaths were found to be present in San Francisco: the gay and economically wealthy Castro district, and the Tenderloin area, which is associated with injecting drug use and poverty.
When the results were analysed, it was established that after the introduction of HAART, patients living in poorer areas (average income below $25,000 pa), had a significantly higher death rate than patients in wealthier areas (p=.001). In addition, patients with AIDS living in poorer areas were more likely to be women, nonwhite, injecting drug users, and gay men with a history of injecting drug use.
However, the investigators found that there was no difference in survival between richer and poorer patients prior to the widespread availability of HAART in 1996. What’s more after 1996, the survival of patients receiving HAART was identical, regardless of social and economic status. This suggested that it was ability to access effective anti-HIV therapy which was the key to survival.
”Socioeconomic status was a significant predictor of survival among San Franciscan residents with AIDS after 1996” note the investigators, adding “the estimated proportion of persons surviving 5 years after AIDS diagnosis was less than 70% for persons residing in the poorest neighbourhoods of San Francisco compared with greater than 85% for persons in the wealthiest districts.” The investigators stress how robust their data are, with the relationship between death and social status holding after controlling for older age and CD4 cell count at diagnosis.
Seeking to explain the finding, the investigators highlight that HAART has made evident “a disquieting feature of American healthcare: the development of expensive complicated therapy leads to disparities in health”, and they call for better provision of healthcare for socially disadvantaged people with HIV.
Further information on this website
Prognosis - factsheet
Factors affecting disease progression - overview
McFarland W et al. Low socioeconomic status is associated with a higher rate of death in the era of highly active antiretroviral therapy, San Francisco. JAIDS, 33: 96 – 103, 2003.