LOWER SOCIOECONOMIC-STATUS AND SHORTER SURVIVAL FOLLOWING HIV-INFECTION

We studied the association between socioeconomic status and survival i n a prospective study of 364 HIV-infected homosexual men who were recr uited during 1982-84. The participants were divided by annual income; those earning above Canadian $10 000 (high-income; n=274) and those be low $10 000 (low-income; n=90) at recruitment. The latter threshold cl osely approximated to the poverty level for this population. Low incom e men were significantly younger than high income men but the groups w ere similar with respect to baseline CD4 counts, subsequent use of ant i-retrovirals and prophylaxis against Pneumocystis carinii pneumonia ( PCP), and number of visits attended during follow-up. Subjects were fo llowed for a median of 9.5 years (range 1.8-13.1). By Dec 31, 1993, th ere were 135 deaths yielding a cumulative mortality rate of mean 45% ( SD 4.0) at 11.5 years. Men aged 30 or more at infection had poorer sur vival than those under 30 (mortality risk ratio 1.56; 95% CI 1.09-2.24 ; p=0.015), and longer survival was significantly associated with a hi gher CD4 count at the earliest seropositive visit. The age-adjusted mo rtality risk ratio for low income men compared with high income men wa s significantly increased at 1.63 (95% CI 1.11-2.40; p=0.013). The sig nificant risk of death for low income men persisted despite adjustment for age at infection, CD4 count, use of zidovudine, dideoxyinosine, a nd dideoxycytidine, use of PCP prophylaxis, and year of infection. We cannot attribute our findings to income loss as a result of more rapid HIV progression because the same effect was present in people who pro vided income data before seroconversion. Similarly, our findings are n ot due to differential access to care because the study was done withi n the context of a universal health care system, and the two income gr oups received treatments equally. This finding is consistent with the association socioeconomic status with increased mortality observed wit hin large populations and in other diseases.