HIGHER SOCIOECONOMIC-STATUS IS ASSOCIATED WITH SLOWER PROGRESSION OF HIV-INFECTION INDEPENDENT OF ACCESS TO HEALTH-CARE

In order to identify socioeconomic characteristics associated with slo wer progression of HIV infection, we conducted a nested case-control s tudy within a cohort of 729 homosexual men. The study compared non-pro gressors (defined as subjects who, at a follow-up visit during the per iod October 1989-December 1990, had been HIV positive for at least 5 y ears, had a CD4 count > 0.5 x 10(9)/1, had a Karnofsky score of 100%, were at Centers for Disease Control (CDC) Stage III or less, and had n ever received zidovudine or prophylaxis against Pneumocystis carinii p neumonia) with rapid progressors (defined as those who had developed A IDS other than Kaposi's sarcoma within 6 years of seroconversion, or w ithin 5 years of enrollment if already seropositive). Rapidly progress ing subjects were matched to non-progressing subjects on the basis of date of enrollment if seroprevalent and date of seroconversion if sero incident. Socioeconomic data were taken from the questionnaire obtaine d at enrollment into the cohort during 1982-84. There were 41 subjects in each group. A significantly higher proportion of the non-progresso rs had annual incomes above $10,000 at enrollment (85 vs 62%; p = 0.01 9). Similarly, a greater proportion of the non-progressors were more l ikely to have finished secondary school (100 vs 84%; p = 0.020) than r apid progressors. A higher proportion of non-progressors reported empl oyment in management and professional positions (35 vs 15%). The non-p rogressing group also had a significantly higher socioeconomic index b ased on self-reported occupation (45.1 vs 38.3; p=0.035). The associat ion with higher income persisted even after adjustment for baseline CD 4 count and symptoms. These associations are not easily explained by a ccess to care since all subjects were covered by universal health insu rance and received a standardized approach to disease management withi n the context of a cohort study. Differential access to anti-retrovira l therapy or PCP prophylaxis cannot be responsible since none of the n on-progressing group, by definition, had ever received these intervent ions. The socioeconomic differences were present at baseline, and prio r to infection in the seroconverting group, so that downward socioecon omic drift due to advancing disease cannot explain the observations. W e conclude that additional elements of the host-agent-environment inte raction, other than access to care but affected by socioeconomic statu s, are likely to be involved in this lesser susceptibility to the effe cts of HIV. Possible modalities include psychosocial factors and nutri tion.