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%) |