Detrimental Effect of a High Adversity Score on HIV Care in the Era of Highly Active Anti-Retroviral Therapy

Socially disadvantaged HIV+ patients in the United States experience unacceptably high rates of AIDS and death. We developed a scoring system to quantify the impact of adverse socio-economic events on HIV care. This retrospective cohort study included 431 HIV+ subjects who initiated HAART between 2000 and 2005 in a university-based Infectious Diseases clinic in St Louis, MO. Poor outcome was defined as having either clinical failure (progression to AIDS or death) or laboratory failure (VL > 400 copies/ml or CD4 <200 cells/µl at 6 months). Seven psychosocial variables were associated with increased risk of poor outcome and used for the adversity score (male gender, non-white race, income <$0,000/year, being a single parent, cocaine abuse, depression, other psychiatric disorders). The score was categorized into quartiles determined by the cumulative number of psychosocial variables (from least to most). Rates of poor outcome were 6%, 26%, 42%, and 68% for quartile 1, 2, 3, 4 respectively. Progression to a higher quartile significantly increased odds of poor outcome (OR = 2.58, 95% CI = 1.96, 3.36). The odds of poor outcome decreased but remained significant at 2.13 (95% CI = 1.57, 2.88) after adjusting for possible mediators (poor access to care, more advanced disease at baseline, poor adherence). In our study, high adversity scores were associated with a greater likelihood of poor outcome in HIV+ patients initiating HAART. Measures targeting socioeconomic issues need to be part of a truly effective therapeutic strategy.