Socioeconomic Score Predicts Detectable Viral Load in French Study
September 28, 2015
A poor socioeconomic score -- largely driven by financial difficulties -- independently doubled chances that HIV-positive adults in France would have a detectable viral load. Although half of the study participants came from Sub-Saharan Africa, this two-center study using the Evaluation of Deprivation and Inequalities in Health Examination Centers (EPICES) score found no link between country of origin and detectable viral load.
Abundant research, much of it from the United States, links lower socioeconomic status to inconsistent engagement in HIV care, poor antiretroviral adherence and inferior response to antiretroviral therapy (ART). But indices of socioeconomic status vary from study to study, a limitation making comparisons difficult. French researchers have used the EPICES score as a standard scale reflecting an array of socioeconomic factors that contribute to individual deprivation, often in studies of diabetes.
Researchers from two Paris-area university hospitals in Clamart and Bobigny conducted this study to assess the EPICES scale as a predictor of poor virologic response to ART. The study involved HIV-positive people attending outpatient clinics of the two hospitals between May 2013 and October 2014. All had taken ART for at least six months, and all answered the EPICES questionnaire, which includes 11 binary questions on social benefit, health insurance, family structure, income, financial difficulties, leisure activities and social support. The resulting score ranges from 0 (least deprived) to 100 (most deprived), with a score >30.17 indicating deprivation. The researchers used logistic regression to identify factors independently associated with viral replication (>50 copies/mL) at the first outpatient clinic visit during the study period.
The analysis included 475 adults with HIV, 394 (83%) with a viral load below 50 copies/mL and 81 with a higher viral load. Just over half of participants (53%) were men, with no difference between the undetectable and detectable groups. Median age was 47 in both groups, and the undetectable group had a higher proportion of men who have sex with men (MSM) (12.7% versus 3.7%) and a lower proportion of heterosexual women (39.6% versus 53.1%) (P < 0.01). A lower proportion of people with an undetectable load came from sub-Saharan Africa (47.5% versus 54.3%, P = 0.04).
Median EPICES score for the whole group stood at 47.9, and 351 participants (74%) had a score above the cutoff indicating deprivation. Median EPICES score proved significantly lower in people with an undetectable versus a detectable viral load (45.9 versus 56.2, P < 0.01). The proportion of participants with an EPICES score indicating deprivation was lower in the group with an undetectable viral load than in the group with detectable viremia (71% versus 87.6%, P < 0.01).
Logistic regression analysis determined that an EPICES score above the deprivation cutoff of 30.17 more than doubled the odds of a detectable viral load (adjusted odds ratio [aOR] 2.29, 95% confidence interval [CI] 1.17 to 4.96). Compared with MSM, people who acquired HIV heterosexually had a tripled chance of detectable viremia (aOR 3.21, 95% CI 1.05 to 13.86). Every additional year of age lowered the odds of a detectable viral load 2% (aOR 0.98, 95% CI 0.95 to 1.00). Among the individual components of the EPICES score, only financial difficulty was associated with detectable viremia, more than doubling the odds (aOR 2.39, 95% CI 1.39 to 4.29). Geographic origin and gender did not affect chances of a detectable viral load in this analysis.
The researchers propose that individual indices of socioeconomic status -- such as the EPICES score -- can help pinpoint specific characteristics that affect clinical outcomes in people with HIV infection. In a 2002-2007 study across 392 French administrative districts, EPICES correlated strongly with two other individual socioeconomic indices, the Townsend and Carstairs scales. The predictive power of such indices in countries without free HIV care and ART remains to be studied.
Mark Mascolini is a freelance writer focused on HIV infection.
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