title: Socioeconomic status and treatment outcomes for individuals with HIV on antiretroviral treatment in the UK: cross-sectional and longitudinal analyses.
abstract: BACKGROUND
  Few studies have assessed the effect of socioeconomic status on HIV treatment outcomes in settings with universal access to health care. Here we aimed to investigate the association of socioeconomic factors with antiretroviral therapy (ART) non-adherence, virological non-suppression, and virological rebound, in HIV-positive people on ART in the UK.
  
  
  METHODS
  We used data from the Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) questionnaire study, which recruited participants aged 18 years or older with HIV from eight HIV outpatient clinics in the UK between Feb 1, 2011, and Dec 31, 2012. Participants self-completed a confidential questionnaire on sociodemographic, health, and lifestyle issues. In participants on ART, we assessed associations of financial hardship, employment, housing, and education with: self-reported ART non-adherence at the time of the questionnaire; virological non-suppression (viral load >50 copies per mL) at the time of questionnaire in those who started ART at least 6 months ago (cross-sectional analysis); and subsequent virological rebound (viral load >200 copies per mL) in those with initial viral load of 50 copies per mL or lower (longitudinal analysis).
  
  
  RESULTS
  Of the 3258 people who completed the questionnaire, 2771 (85%) reported being on ART at the time of the questionnaire, and 2704 with complete data were included. 873 (32%) of 2704 participants reported non-adherence to ART and 219 (9%) of 2405 had virological non-suppression in cross-sectional analysis. Each of the four measures of lower socioeconomic status was strongly associated with non-adherence to ART, and with virological non-suppression (prevalence ratios [PR] adjusted for gender/sexual orientation, age, and ethnic origin: greatest financial hardshipvsnone 2·4, 95% CI 1·6-3·4; non-employment 2·0, 1·5-2·6; unstable housingvshomeowner 3·0, 1·9-4·6; non-university education 1·6, 1·2-2·2). 139 (8%) of 1740 individuals had subsequent virological rebound (rate=3·6/100 person-years). Low socioeconomic status was predictive of longitudinal rebound risk (adjusted hazard ratio [HR] for greatest financial hardshipvsnone 2·3, 95% CI 1·4-3·9; non-employment 3·0, 2·1-4·2; unstable housingvshomeowner 3·3, 1·8-6·1; non-university education 1·6, 1·1-2·3).
  
  
  CONCLUSIONS
  Socioeconomic disadvantage was strongly associated with poorer HIV treatment outcomes in this setting with universal health care. Adherence interventions and increased social support for those most at risk should be considered.
  
  
  BACKGROUND
  National Institute for Health Research.
authors.affiliation: Research Department of Infection and Population Health, University College London, London, UK.
authors.forename: Lisa S
authors.initials: LS
authors.lastname: Burch
authors.affiliation: Research Department of Infection and Population Health, University College London, London, UK.
authors.forename: Colette J
authors.initials: CJ
authors.lastname: Smith
authors.affiliation: Centre for the Study of Sexual Health and HIV, Homerton University Hospital NHS Foundation Trust, London, UK.
authors.forename: Jane
authors.initials: J
authors.lastname: Anderson
authors.affiliation: Research Department of Infection and Population Health, University College London, London, UK.
authors.forename: Lorraine
authors.initials: L
authors.lastname: Sherr
authors.affiliation: Research Department of Infection and Population Health, University College London, London, UK.
authors.forename: Alison J
authors.initials: AJ
authors.lastname: Rodger
authors.affiliation: Barts Health NHS Trust, London, UK.
authors.forename: Rebecca
authors.initials: R
authors.lastname: O'Connell
authors.affiliation: Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.
authors.forename: Anna-Maria
authors.initials: AM
authors.lastname: Geretti
authors.affiliation: Research Department of Infection and Population Health, University College London, London, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Gilson
authors.affiliation: Royal Sussex County Hospital, Brighton, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: Fisher
authors.affiliation: School of Health Sciences, City, University of London, London, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Elford
authors.affiliation: East Sussex Healthcare NHS Trust, Eastbourne, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: Jones
authors.affiliation: HIV i-Base, London, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Collins
authors.affiliation: National AIDS Trust, London, UK.
authors.forename: Yusef
authors.initials: Y
authors.lastname: Azad
authors.affiliation: Research Department of Infection and Population Health, University College London, London, UK.
authors.forename: Andrew N
authors.initials: AN
authors.lastname: Phillips
authors.affiliation: Research Department of Infection and Population Health, University College London, London, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Speakman
authors.affiliation: Royal Free London NHS Foundation Trust, London, UK.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Johnson
authors.affiliation: Research Department of Infection and Population Health, University College London, London, UK.
authors.forename: Fiona C
authors.initials: FC
authors.lastname: Lampe