Impact of neighborhood-level socioeconomic status on HIV disease progression in a universal health care setting

Objectives: The objectives of this study were to examine neighborhood measures of socioeconomic status and their effect on the risk of mortality among HIV-positive persons accessing and not accessing treatment, the effects of late access to treatment by CD4 cell count, and survival among those who accessed treatment. Methods: We limited our analysis to the era of highly active antiretroviral therapy (HAART). We used individual-level patient and clinical characteristics and neighborhood-level socioeconomic data to address our objectives. The Pearson chi(2) and Wilcoxon sign rank tests were used to compare mortality among HIV-positive persons accessing and not accessing treatment, logistic regression models were used to compare persons who accessed treatment with low CD4 cell counts (< 50 CellS/mm(3)) with those who accessed treatment earlier (CD4 count >= 50 cells/mm(3)), and Weibull survival models were used to compare mortality among those who accessed treatment. Results: Forty percent of people who died from HIV/AIDS-related causes never accessed treatment. Among those who accessed treatment, 16% did so when their CD4 counts were < 50 cells/mm(3). Unemployment was associated with delayed access to treatment (odds ratio = 1.41, 95% confidence interval [CI]: 1.14 to 1.74). Postsecondary education (hazard ratio [HR] = 0.80, 95% CI: 0.71 to 0.91) and percent of residents below the poverty line (HR = 1.07, 95% Cl: 1.01 to 1.13) were associated with mortality. Conclusions: In a setting where treatment for HIV is free of charge, a significant number of HIV-positive persons did not access HAART. Low socioeconomic status was associated with this delay and with increased mortality among persons receiving HAART. Social and health policy initiatives, beyond free and universal health care, are required to optimize access to HAART.