The effect of socioeconomic disadvantage on strategies to end the AIDS epidemic

COMMENTARY

As Henry David Thoreau, American author, poet, and philosopher, once stated, “The price of anything is the amount of life you exchange for it” (1). In the case of life expectancy, the average number of additional years that a person of a specific age will live, considerable differences in years lived have been observed to result from people’s ability to access economic (e.g. income), cultural (e.g. education), and social (e.g. social supports) capital within a society (2–4). Those with less, relative to their income or social status, often pay the most for the length of life they live. Thus, when assessing life expectancy, the price of anything is everything (5).

Among people living with HIV (PLHIV), the uptake of highly active antiretroviral therapy (HAART) has been associated with increased life expectancy. For the first time, PLHIV can expect to live almost as long as their counterparts in the general population (6). However, as with the general population, a number of health inequities have been observed amongst PLHIV, with stark differences in health outcomes that follow along the lines of ethnicity, gender, and geography (7,8), and multiple large cohorts and studies provide evidence of this. The Antiretroviral Cohort Collaboration (ART-CC) has noted differences in life expectancy between women and men, individuals with a history of injection drug use and those who do not, as well as regional differences between North America and Europe, although these differences may be attributed in part to issues of death ascertainment between cohorts (9). The North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) has observed differences by ethnicity, with lower life expectancies among African Americans versus other ethnicities (6). Similarly, the Canadian Observational Cohort Collaboration (CANOC) has observed differences between Indigenous persons and other ethnicities in Canada (10). Moreover, a number of studies have observed differences in life expectancy by transmission group, with persons who have a history of injection drug use having lower life expectancies than other populations (6,10,11). Finally, the lack of differences in life expectancy between men and women indicates that women living with HIV are more disadvantaged relative to their counterparts in the general population (12).

In this issue of the Lancet Public Health, Lisa Burch and colleagues (13) reported that among people treated for HIV in the United Kingdom, lower socio-economic status (i.e. financial hardship, non-employment, rented/unstable housing status, and no university education) were strongly associated with HAART non-adherence and virological non-suppression. Among those who were virally suppressed at baseline, each marker of lower socio-economic status noted above was predictive of subsequent virological rebound. As the authors note, in this universal healthcare setting these findings suggest that the implications of poorer socioeconomic status “clearly go beyond lack of ability to pay for treatment and healthcare, and operate strongly even amongst those who are engaged with clinical care” (13).

Our attention should, thus, turn towards supporting HAART adherence, an essential component of virological suppression (14) and HIV prevention (15), particularly among subpopulations that experience greater disadvantage. Factors associated with mortality and unsuppressed viral load mirror those associated with suboptimal adherence. Individuals that exhibit greater vulnerability to suboptimal HAART adherence include individuals who inject drugs and do not access methadone or opioid substitution (16), have problematic use of crack, cocaine, and alcohol (17), experience symptoms of depression (18), and women (19). Marginalization associated with HIV and the above-listed factors is compounded by stigma and discrimination (20), stress (21), trauma (22), and lack of social support (23), all of which have been shown to undermine HAART adherence.

If we are to meet the Treatment as Prevention inspired UN 90-90-90 Target (24), even in high and very high human development index countries, we must acknowledge the impact of lower socio-economic status on HIV treatment outcomes and ultimately survival. If we fail to address social disadvantage in its many manifestations, we risk exacerbating health inequities. This is not a new phenomenon; the link between income and survival was prospectively observed early in the epidemic (25), nor, as noted by Burch and colleagues, is it limited to HIV (13). Clearly, indirect investments of socioeconomic status will be needed – and as Thoreau notes, these will not come cheap.