People with HIV who have less schooling have worse results after starting antiretroviral therapy [ART], according to data from a large cohort of European collaboration published in the online edition of the Journal AIDS. Mortality and AIDS rates decreased with increasing levels of education, and education was also associated with viral suppression and CD4 counts at the time of initiation of antiretroviral therapy.
"Significant differences in mortality and clinical response to antiretroviral therapy could not be fully explained by the delay in the diagnosis of HIV infection or the late start of antiretroviral therapy, since the differences persisted even after analyzes restricted to those starting CD4 treatment > 350 cells / mm3 and no previous diagnoses of AIDS, "the authors commented. "The associations we find between schooling and clinical outcomes are probably mediated by material means and, of course, psychosocial pathways."
Even in countries with free access to health care, the group that makes up the "base of the Social Pyramid" with a lower socioeconomic level is associated with worse health outcomes. Researchers co-collaborated with several HIV cohort studies and observational study collaboration HIV epidemiological research in Europe, constitutes a coherent approach () - and has already shown that late diagnosis of HIV and early antiretroviral therapy with a low CD4 count are associated with lower levels of education.
Researchers now wanted to see if disparities in health outcomes from education persisted after the start of antiretroviral therapy.
Therefore, a study was designed to examine differences in educational level in mortality and new aids after initiation of antiretroviral therapy [ART] and also viral suppression and changes in CD4 counts.
Data from 15 cohort studies in eight countries were available for analysis. Adult patients starting antiretroviral therapy for the first stage between 1996 and 2013 were eligible for inclusion. Schooling was normalized across the cohorts.
The main outcomes were:
- All causes of mortality.
- New AIDS or death event.
- Virological suppression - two successive measurements of viral load below 400 copies / ml. (Translator's note: this was what could be measured in 2013 - today there are tests, usually used in research, capable of detecting counts in excess of only five copies of HIV RNA)
- Increased CD4 cell count during the first six years of Antiretroviral Therapy.
The results were adjusted in order to evaluate differences such as gender, age at the start of antiretroviral therapy, time at which antiretroviral therapy started (before 2001; 2001-2004; 2005-2008; 2009-2013); antiretroviral therapy before viral load measurement and / or CD4 count; measurement of pre-ART viral load against AIDS and type of antiretroviral therapy.
A total of 24,069 people were eligible for inclusion. Overall, 9% had not completed primary schooling; 32% had only primary education; 44% had completed secondary education and 14% had a college education or equivalent.
Individuals with a high school level were more prominent in being male and belonging to the contagion group represented as MSM (Men who have sex with men – WARNING MARRIED WOMEN). One-fifth of the women were in levels of lower schooling.
There was an association between education and mortality. During 132,507 person-years of analysis, 1081 people died. Mortality decreased with increased educational level (p <0,001) and these differences persisted in models that previously adjusted for potential error factors. People with a college education had a lower risk of death than all other education groups. A similar mortality pattern was present in an analysis controlling the timing of initiation of antiretroviral therapy, CD4 count, onset of antiretroviral therapy prior to AIDS, and also age at the time treatment was initiated.
A significant association was also present between educational level, mortality, and AIDS. More than 122,765 person-years, there were 2598 new clinical manifestations or deaths. Differences in the incidence of AIDS / death by level of education were even more pronounced than for death alone (p <0,001).
One year after starting HIV therapy, 77% of patients had achieved viral suppression. This was achieved by 67% of people with incomplete elementary education, 85% of individuals with a primary education, 82% of individuals with upper secondary education and 87% of individuals attending a university (p <0,001).
Differences in outcomes between the groups became less pronounced over time and ceased to be significant after ten years of therapy. After adjusting for possible error factors, those with incomplete elementary education or primary education were likely to achieve a lower virological response of only twenty-seven percent, respectively, than patients who attended college.
Returning to the immunological results, the data showed that the higher the level of schooling reached, the higher the CD4 count at the beginning of ART. However, there was no evidence that level of schooling was associated with recovery of CD4 counts six months after initiation of therapy.
"HIV positive patients on combination antiretroviral therapy who had lower schooling had higher mortality rates, higher rates of clinical events, and worse than patients with better responses to care for viral load who had more education," the authors write. authors. "We observed such health differentials over a period of eighteen years in eight European countries where access to health care and ART is universal."
Translated by Claudio Original Souza- in English Educational attainment associated with health outcomes after starting HIV therapy written by Michael Carter and originally published in AIDSMAP.COM in 11 October 2016. Reviewed by Mara de Macedo.
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