Increased risk of virological failure to the first antiretroviral regimen in HIV-infected migrants compared to natives: data from the ICONA cohort.
BACKGROUND
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.
Clinic of Infectious Diseases, University of Bari, Bari, Italy.
Annalisa
A
Saracino
Clinical Department, National Institute for Infectious Diseases "L. Spallanzani" IRCCS, Rome, Italy.
Patrizia
P
Lorenzini
Clinic of Infectious Diseases, Santissima Annunziata Hospital, Florence, Italy.
Sergio
S
Lo Caputo
Department of Epidemiology, National Institute for Infectious Diseases "L. Spallanzani'' IRCCS, Rome, Italy.
Enrico
E
Girardi
Division of Infectious and Tropical Diseases, Civili General Hospital, University of Brescia and Spedali Brescia, Italy.
Francesco
F
Castelli
Department of Infectious Diseases, Azienda Ospedaliera Lecco, Lecco, Italy.
Paolo
P
Bonfanti
Department of Infectious Diseases, L. Sacco University Hospital, University of Milan, Milan, Italy.
Massimo
M
Galli
Department of Infectious Diseases, Amedeo di Savoia Hospital, Turin, Italy.
Pietro
P
Caramello
Department of Infectious Diseases, Cotugno Hospital, Naples, Italy.
Nicola
N
Abrescia
Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy.
Cristina
C
Mussini
Clinic of Infectious Diseases, University of Bari, Bari, Italy.
Laura
L
Monno
Clinic of Infectious Diseases, San Paolo Hospital, University of Milan, Milan, Italy.
Antonella d'Arminio
Ad
Monforte