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Temporary Employment, Absence of Stable Partnership, and Risk of Hospitalization or Death During the Course of HIV Infection in France
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JAIDS Journal of Acquired Immune Deficiency Syndromes: Volume 40(2) 1 October 2005
Dray-Spira, Rosemary MD, the PRIMO Cohort Study Group
From *INSERM U687-IFR69, Hôpital National de Saint-Maurice, Saint-Maurice, France; INSERM U569-Service d'Epidemiologie,
The aim of this study was to estimate the independent association between socioeconomic situation and the risk of all-cause hospitalization or death during the course of HIV disease among a population of HIV-infected patients followed from the time of primary infection in France.
".....social conditions are independently associated with patients' health status during the first years of the disease. Patients with nonpermanent employment are at increased risk of hospitalization or death compared with those with stable employment, as are patients without any stable partnership compared with those with a stable partnership. This last finding is consistent with recent data reporting a higher rate of progression to AIDS or death among HAART-treated patients without a stable partnership in the Swiss HIV cohort study..."
Abstract
Objective: To estimate the independent association between socioeconomic conditions and the risk of all-cause hospitalization or death during the course of HIV disease in the highly active antiretroviral therapy (HAART) era.
Methods: Patients in the French PRIMO multicenter prospective cohort of 319 individuals were enrolled during primary HIV-1 infection between 1996 and 2002. Associations between social characteristics (ie, employment status, stable partnership) and the risk of hospitalization or death were assessed using generalized estimating equations.
Results:
During a median follow-up of 2.5 years, 109 hospitalizations among 84 patients (26.3%) and 3 deaths occurred.
Even after adjustment for classic determinants of HIV-infected patients' health status, social characteristics were independently associated with the risk of hospitalization or death, with a significantly increased risk for patients with temporary employment compared with those with stable employment (adjusted odds ratio [OR] = 2.5, 95% confidence interval: 1.1 to 5.6) and for patients without a stable partnership compared with those with a stable partnership (OR = 1.6, 95% confidence interval: 1.0 to 2.7).
Conclusions: In the era of HAART, adverse social conditions constitute independent risk factors of hospitalization or death during the course of HIV disease.
Causes of Hospitalization or Death
A diagnosis was documented for 108 of the 109 hospital admissions and for all 3 deaths that occurred during follow-up. As shown in Table 3, major causes of hospitalization included complications of HIV infection or HAART (fever, asthenia, drug-related liver disease, renal lithiasis, gastrointestinal disease, or dermatosis) in 27 hospitalizations (25.0%) and mental disorders (mainly depressive symptoms) in 23 hospitalizations (21.3%). Other causes of hospitalization (mostly non-HIV-related infections and surgical reasons) were reported for 58 inpatient admissions (53.7%). Causes of the 3 deaths were tuberculosis, suicide, and lymphoma.
Patients were predominantly male (82.2%) and natives of France or another European country (89.4%). The median age at enrollment was 33.6 years (range: 15.1 to 72.9 years). Most of the patients had been infected with HIV through homosexual or bisexual (62.4%) or heterosexual (27.3%) contact. Most (n = 248 [77.7%]) were employed at enrollment, among whom 19 had a nonpermanent job, and a stable partnership was reported by 196 patients (61.3%). At enrollment, 13 patients (4.1%) had severe immunosuppression with a CD4 cell count less than 200/mm3. A prescription for HAART was initiated on the day of enrollment in 218 patients (68.3%). After 1 year of follow-up, 224 (79.4%) of the 282 patients who had attended the M12 visit were being prescribed antiretroviral therapy (95% HAART). Thirty-eight patients (11.9%) had at least 1 chronic disease in addition to HIV infection at enrollment. Smoking was reported by 167 patients (52.4%), and ongoing injection drug use was reported by 3 patients (0.9%).
DISCUSSION
To our knowledge, although social issues have been weighing more and more on HIV clinical practice in Western countries as the disease has become chronic and the epidemic has shifted toward more socially vulnerable populations, only a few studies have focused on the relations between employment status, stable partnership, and health status during HIV infection. Of particular interest in our study is that patients were enrolled at the early stage of primary infection and prospectively followed afterward, allowing for the documentation of events occurring during the whole course of the disease, including early after infection.
Our results show that in the context of our cohort of HIV-infected patients in the era of HAART, even after adjustment for acknowledged health determinants of HIV-infected patients, social conditions are independently associated with patients' health status during the first years of the disease. Patients with nonpermanent employment are at increased risk of hospitalization or death compared with those with stable employment, as are patients without any stable partnership compared with those with a stable partnership. This last finding is consistent with recent data reporting a higher rate of progression to AIDS or death among HAART-treated patients without a stable partnership in the Swiss HIV cohort study.12
Our finding of an association between social conditions and health status may be interpreted in 2 ways: these characteristics may constitute determinants but also consequences of changes in health status, with the sicker patients being less likely to stay in a stable partnership or employment. Thanks to the fact that employment and partnership status were measured before the outcome, to our conservative definition of these characteristics, and to systematic adjustment for time-dependent health status, the associations we show are unlikely to reflect an effect of health deterioration on employment and partnership status. As in any observational study, however, unmeasured confounding may have occurred, and causality can not definitely be established.17
Moreover, several considerations suggest that the strength of the associations between social characteristics and health status may be underestimated in the present study. The cohort design is probably biased toward selection of the most socially privileged patients in our study sample: to be enrolled in the PRIMO cohort, patients had to be diagnosed as infected with HIV at the early stage of primary infection and had to become involved in a long-term prospective follow-up, conditions that are likely to exclude the most socially fragile patients.18 Thus, the social heterogeneity observed in our study sample is likely to be lower than in the entire population of HIV-infected patients in France. Moreover, social differences in health care (eg, differences in outpatient visit frequency or in access to antiretroviral treatments) reported among wider populations of HIV-infected patients19 are less likely to happen in the context of such a cohort study.
Although dropout may have biased our estimations, the fact that patients lost to follow-up were comparable to those followed regarding baseline characteristics and experience of hospitalization during follow-up (30.6% vs. 25.8%) and that most of them had stable employment (83.3%) and were in a stable partnership (80.6%) at the last follow-up visit is reassuring.
Social conditions may affect the risk of hospitalization or death in several ways. In the present study, patterns of health care use may differ according to patients' social characteristics and social distress may constitute, independent of health status, an important motivation for inpatient admission among the most socially fragile patients. Causes and lengths of hospitalization did not show obvious differences according to patients' social characteristics (although the sample size allowed little power to detect such differences), suggesting that such social inpatient admissions do not explain the differences observed in the risk of hospitalization or death according to social characteristics.
Thus, the relations we found between social characteristics and health status may be explained by different processes. First, temporary employment and the absence of a stable partnership may themselves generate stress with direct physiologic effects on the neuroendocrine and immune systems, resulting in HIV disease progression. Such a mechanism has been demonstrated for other stressful life events (eg, bereavement).20-24 Second, as indirect consequences of such stress, temporary employment and the absence of a stable partnership may result in increased risky health behaviors (smoking, alcohol, or drug consumption), adverse psychologic effects, and poorer treatment adherence.25-29 In the PRIMO cohort, questions on alcohol use were included in the questionnaire only recently (in 1999) and thus could not be considered for this early analysis; in addition, drug use was rare. Thus, although multivariate analysis was adjusted for available data on health behaviors, a part of the observed relations between social characteristics and health status may be explained by differences in these unmeasured risky behaviors. However, mental disorders and poor treatment adherence, which were documented longitudinally, were not reported more frequently in case of temporary employment or the absence of a stable partnership. Third, the absence of a stable partnership may be a wider indicator of lack of social support and/or social isolation, which have been independently related to increased rates of mortality and morbidity in the general population.30-33 Fourth, nonpermanent employment may be associated with adverse working conditions (eg, high level of physical demand, low control over work pace and scheduling, increased tension and conflicts at work), which may have an effect on patients' health status.34 Temporary employment may also be the result of a health selection process previous to HIV infection in which patients with the poorest health status and/or the least healthy lifestyle have been selected.29
Unemployment has been shown to be associated with increased mortality in the general population.35,36 Among our cohort of HIV-infected patients, the increased risk of hospitalization or death associated with unemployment seems to be lower than that associated with nonpermanent employment. In our sample, frequencies of risky health behaviors, mental disorders, and poor treatment adherence are higher among unemployed patients than among those with stable employment, and these differences partly explain the increased risk of hospitalization or death observed among the unemployed patients in univariate analysis. Moreover, in France, unemployed HIV-infected patients may have access to disability benefits, which may result in less stress and higher incomes compared with patients with temporary employment, who have to face employment disruptions.37
Overall, more than a quarter of the patients have been hospitalized at least once during a median follow-up period of 2.5 years, a rate that seems to be high in this population of young, recently HIV-infected, largely HAART-treated, and mostly non-hepatitis C virus-coinfected patients. The persisting high risk of inpatient admission in the HAART era reported among ethnic minorities and injection drug users3,9,38 therefore also seems to occur among more socially privileged patients. The proportion of hospital admissions motivated by mental disorders was high (21.3%). The result indicating that the risk of hospitalization or death is higher during the first year of follow-up compared with the later period was unexpected. This finding was not attributable to a higher frequency of side effects related to the start of antiretroviral treatment or to psychologic distress in reaction to diagnosis during this period. As suggested by sociologic studies,39,40 the biographical disruption consecutive to a diagnosis of chronic illness may lead to a period of increased social and health vulnerability.
In conclusion, in the era of HAART, the risk of hospitalization is high from the first months of HIV disease. Early psychologic support should seek to prevent a portion of these hospitalizations occurring at the early stages of the disease. Adverse social conditions, namely, temporary employment and the absence of a stable partnership, constitute independent risk factors of poor health status as defined by all-cause hospitalization or death among HIV-infected patients. Further studies with more detailed data on patients' living conditions should provide a better understanding of the mechanisms of such social health inequalities in this specific context.
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