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Inequalities by educational level in response to combination antiretroviral treatment and survival in HIV-positive men and women in Europe

Type of publication Peer-reviewed
Publikationsform Original article (peer-reviewed)
Author Del Amo Julia, Socio-economic Inequalities and HIV Working Group,
Project Swiss HIV Cohort Study (SHCS)
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Original article (peer-reviewed)

Journal AIDS
Page(s) 253 - 262
Title of proceedings AIDS
DOI 10.1097/qad.0000000000001270

Open Access

Type of Open Access Repository (Green Open Access)


BACKGROUND 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. METHODS 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. RESULTS 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.