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Journal of the International AIDS Society logoLink to Journal of the International AIDS Society
. 2014 Nov 2;17(4Suppl 3):19769. doi: 10.7448/IAS.17.4.19769

Increased risk of virological failure to the first antiretroviral regimen in HIV-infected migrants compared to natives: data from the ICONA cohort

Annalisa Saracino 1, Patrizia Lorenzini 2, Sergio Lo Caputo 3, Enrico Girardi 4, Francesco Castelli 5, Paolo Bonfanti 6, Massimo Galli 7, Pietro Caramello 8, Nicola Abrescia 9, Cristina Mussini 10, Laura Monno 1, Antonella d'Arminio Monforte 11
PMCID: PMC4225436  PMID: 25397513

Abstract

Introduction

Aim of the study was to evaluate possible disparities in access and/or risk of virological failure (VF) to the first antiretroviral (ART) regimen for migrants compared to Italian-born patients and to assess determinants of failure for the migrants living with HIV.

Methods

All native and migrant naïve patients enrolled in ICONA in 2004–2014 were included. Firstly, variables associated to ART initiation were analyzed. In a second analysis, the primary endpoint was time to failure after at least six months of ART, defined as: (a) VF (first of two consecutive viral load (VL) >50 and >200 copies/mL); (b) treatment discontinuation (TD) for any reason; and (c) treatment failure (TF: confirmed VL >200 cp/mL or TD). A Poisson multivariable analysis was performed to control for confounders.

Results

A total of 5777 HIV-pos ART-naïve patients (1179 migrants and 4598 natives) were evaluated. Most migrants were from sub-Saharan Africa (35.3%) and South-Central America/Caribbean (29%). Median duration of residency in Italy was five years (IQR 1–10). Baseline characteristics significantly differed between the two groups (Table 1); in particular, lower CD4 counts and higher frequency of AIDS events were observed in migrants vs natives. When adjusting for baseline confounders, migrants presented a lower chance to initiate ART compared to natives (OR 0.78, 95% CI 0.65–0.93, p=0.006). After ART initiation, the incidence rate of VF >50 cp/mL was 15.5 per 100 person-years (95% CI 12.8–18.8) in migrants and 8.9 in natives (95% CI 7.9–9.9), respectively. By multivariable analysis, migrants had a significantly higher risk of VF, both >50 cp/mL (OR 1.50, 95% CI 1.17–1.193, p=0.001) and >200 cp/mL (OR 1.59, 95% CI 1.23–2.05, p<0.001), and of TF (OR 1.15, 95% CI 1.00–1.32, p=0.045), while no differences were observed in TD risk. Among migrants, variables associated with a higher VF risk were age (for 10-year increase, OR 0.96, 95% CI 0.93–0.98, p=0.002), unemployment (OR 1.96, 95% CI 1.20–3.20, p=0.007) and use of a boosted PI based-regimen (OR 2.04, 95% CI 1.25–3.34, p=0.005 vs NNRTI-based), while pregnancy was associated with TD (OR 3.73, 95% CI 2.36–5.90, p<0.001) and TF (OR 3.13, 95% CI 02.00–4.89, p<0.001).

Conclusions

Despite the use of more potent and safer antiretroviral drugs in the last 10 years, and even in a setting of universal access to ART, migrants living with HIV still present barriers to ART initiation and increased risk of VF compared to natives.


Table 1.

Characteristics of migrant and native-born HIV-positive antiretroviral naïve patients enrolled in the ICONA cohort during the period 2004–2014 at time of inclusion

Migrants Natives p
Total n=5777 n=1179 n=4598
Male gender, n (%) 674 (57.2%) 3914 (85.1%) <0.001
Age, yrs, median (IQR) 34 (28–40) 39 (32–47) <0.001
Education, n (%) Less than high 355 (30.1%) 1075 (17.3%) <0.001
High 309 (26.2%) 1980 (43.1%)
Missing 515 (43.7%) 1543 (33.6%)
Employment, n (%) Full employed 444 (37.7) 2786 (60.5%) <0.001
Occasionally employed 99 (8.4%) 78 (1.7%)
Unemployed 353 (30.0%) 554 (14.5%)
Other/missing 229 (19.4%) 1180 (25.7%)
Mode of HIV transmission, n (%) Heterosexual 703 (59.6%) 1634 (35.5%) <0.001
Homosexual 312 (26.5%) 2194 (47.7%)
IVDU 48 (4.1%) 436 (9.5%)
Other/unknown 116 (9.8%) 334 (7.3%)
Recent drug use, n (%) No 904 (76.7%) 3352 (72.9%) 0.005
Yes 21 (1.8%) 149 (3.2%)
Unknown 254 (21.5%) 1097 (23.9%)
Smoke, n (%) No 677 (57.4%) 1757 (38.2%) <0.001
Yes 252 (21.4%) 1780 (38.7%)
Unknown 250 (21.2%) 1061 (23.1%)
Pregnancy status, n (%) 51 (4.3%) 17 (0.4%) <0.001
HIV subtype, n (%) B 203 (17.2%) 1344 (29.2%) <0.001
Non-B 218 (18.5%) 316 (6.9%)
Unknown 758 (64.3%) 2938 (63.9%)
First HIV RNA (per 1 log cp/mL more) 4.5 (IQR 3.7–5.2) 1.6 (IQR 3.9–5.2) 0.066
First CD4 count (per 100 cell/mmc more) 317 (IQR 137–509) 396 (223–577) <0.001
First CD4, cell/mmc <200 324 (27.5%) 876 (19.1%) 0.003
200–350 226 (19.2%) 732 (15.9%)
>350 440 (37.3%) 2197 (47.8%)
Missing 189 (16.0%) 793 (17.3%)
AIDS event pre-treatment, n (%) 140 (11.9%) 362 (7.9%) <0.001
HCV co-infection, n (%) Positive 71 (6.0%) 446 (9.7%) <0.001
Negative 794 (67.3%) 2882 (62.7%)
Unknown 314 (26.6%) 1270 (27.6%)
HBV co-infection, n (%) Positive 58 (4.9%) 144 (3.1%) 0.008
Negative 785 (66.6%) 3060 (66.6%)
Unknown 336 (28.5%) 1394 (30.3%)
CMV co-infection, n (%) Positive 45 (3.8%) 246 (5.3%) <0.001
Negative 492 (41.7%) 1579 (34.3%)
Unknown 642 (54.4%) 2773 (60.3%)

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