Socioeconomic inequality challenges population-level implementation of health interventions. We investigated differences by educational level in clinical, virological and immunological responses to combined Antiretroviral Treatment (cART) in HIV-positive men and women in COHERE, a European collaboration.
Data were pooled from 15 cohorts in eight countries of patients initiating cART in 1996-2013 with data on educational level categorized in UNESCO/ISCED classifications. Kaplan-Meier curves, Cox and piecewise linear mixed models were used.
Of 24,069 HIV-positive patients, 9% had not completed primary education, 32% had completed primary, 44% secondary, and 15% tertiary education. Overall, 21% were women, who were over-represented in lower educational strata. During 132,507 person-years of follow-up, 1,081 individuals died; cumulative mortality decreased with higher educational level (p < 0.001). Over 122,765 person-years, new AIDS events or death occurred in 2,598 individuals; differences by education were more marked than for death alone (p < 0.001). Virological response was achieved by 67% of patients without completed basic education, 85% with completed primary education, 82% with secondary, and 87% with tertiary (p < 0.001). Patients with higher education had higher CD4-count at cART initiation and at each time after cART but rate of CD4-count recovery did not differ. Differences in mortality and clinical responses were similar for men and women and were not entirely explained by delayed HIV diagnosis and late cART initiation. CONCLUSIONS
HIV-positive patients with lower educational level had worse responses to cART and survival in European countries with universal healthcare. To maximize the population impact of cART, Europe needs to decrease the socioeconomic divide.