1. For the ASTRA Study Group
Do socioeconomic factors explain gender differences in virological response to ART in the UK?
R O’Connell, LS Burch, J Anderson, M Johnson, AM Geretti, AJ Rodger, L Sherr, R Gilson, N Perry, J Elford, M Jones, AN Phillips, A Speakman, FC Lampe, CJ Smith
For the ASTRA Study Group

2. Gender and socioeconomic factors in HIV
Biological Susceptibility, immune activation, disease progression compartmentalization, pregnancy, reproductive health Treatment Pharmacokinetics, pharmacodynamics, drug toxicities, viral load outcomes Socioeconomic Testing, access to care, retention in care, mental health and well-being, gender based violence, neighbourhood, food security, housing Research Equity of access: support, treatment and cure
Loutfy MR et al. AIDS Soc 2013;16:18509 ; Rosin C, et al. HIV Med 2015;16(5):319-25; Zheng Yin et el UK Health Protection Directorate; Gueler A, et al. AIDS 2015;29(2):231-8.; Johnston RE, Heitzeg MM. AIDS Res Human Retrovir 2015;31(1):85-97; Hatcher AM, et al. AIDS 2015; 29(16):2183–2194

3. Gender and socioeconomic factors: UK
Higher prevalence in socioeconomically vulnerable areas; MSW and women vs MSM test less in sexual health setting; higher prevalence in Black African Women vs men (71 vs 41 /1000); Black African MSW present late compared to all other groups1
Conflicting evidence for VL outcomes: no difference1,2; worse outcomes for women and MSW vs MSM3; higher VL failure for MSW vs women4
Socioeconomic stress factors associated with viral load rebound despite universal treatment access5
Zheng Yin et al HIV in the United Kingdom 2014 Report;
Sherr L, et al. Women Health. 2012;52(3):
Saunders P et al; HIV Med
Barber TJ et al Antiviral Ther 2011;16(6):805-14
Burch et al CROI 2015 Poster 560

4. Aims
To assess whether socio-economic factors explain observed differences in virological outcomes in MSM and MSW and women in the ASTRA study

5. ASTRA study
Self completed questionnaire survey of 3258 participants (64% response rate) in 8 clinics in the UK
Demographic factors [gender/sexuality, age, ethnicity, stable partner, children, identifies with a religion]
Socio-economic factors [UK birth/English fluency, financial status, employment, housing status, education, supportive network (modified Duke FSS questionnaire)]
Current depression symptoms (PHQ-9)
HIV-related and other health-related factors [time since HIV diagnosis, ART use, disclosure of HIV status, currently pregnant, IDU transmission route]
Lifestyle factors [smoking, possible alcohol dependency (CAGE questionnaire), recreational drug use]
637 women
373 MSW (heterosexual men)
2248 MSM (gay/bisexual men)
Longitudinal linkage to care with additional consent (N= 2983)

6. Statistical methods
Cross sectional: CD4 and VL recorded by clinic at time of questionnaire
Population: on ART, and started at least 6 months ago
Virological outcome: VL >50 copies/ml
Prevalence of VL>50 compared between MSM, MSW and women using modified Poisson regression
Longitudinal: linkage with prospective clinic data for consenting participants (92%); data available for 6 clinics
Population: on ART, and started at least 6 months ago with VL<50 copies/ml at time of questionnaire
Viral rebound: first VL>200 copies/ml
Rate of rebound compared between MSM, MSW and women using Cox Proportional Hazards regression

7. Baseline characteristics: MSM, MSW, women On ART started > 6 months ago N=2445
N (%/ median IQR)
MSM N=1678
MSW N=285
Women N=482
p-value*
Age <40 years
28%
20%
38%
<0.001
White
89%
29%
19%
<0.001 
Black African 1%
54%
66%
Other/missing
10%
17%
15%
UK born
72%
23%
18%
Non-UK born, fluent English
25%
59%
65%
Non-UK born, not fluent English 3%
Time on ART (years)
8.3 (4.0,13.8)
7.1 (3.5, 11.4)
7.2 (3.6,11.1)
CD4
570 (430,750)
472 (328,682)
570 (397,757)
Non-adherence
31%
34%
40%
0.004
Self-reported number of times ≥ 2 consecutive days or ART missed in 2 months prior to questionnaire or 1 or more missed ART dose in past 2 weeks
*chi squared test

8. Baseline characteristics: MSM, MSW, women On ART started > 6 months ago N=2445
N (%/ median IQR)
MSM N=1678
MSW N=285
Women N=482
p-value*
Age <40 years
28%
20%
38%
<0.001
White
89%
29%
19%
<0.001 
Black African 1%
54%
66%
Other/missing
10%
17%
15%
UK born
72%
23%
18%
Non-UK born, fluent English
25%
59%
65%
Non-UK born, not fluent English 3%
Time on ART (years)
8.3 (4.0,13.8)
7.1 (3.5, 11.4)
7.2 (3.6,11.1)
CD4
570 (430,750)
472 (328,682)
570 (397,757)
Non-adherence
31%
34%
40%
0.004
Self-reported number of times ≥ 2 consecutive days or ART missed in 2 months prior to questionnaire or 1 or more missed ART dose in past 2 weeks
*chi squared test

9. Baseline characteristics: MSM, MSW, women On ART started > 6 months ago N=2445
MSM N=1678
MSW N=285
Women N=482
*p-value
Enough money for basic needs
53%
27%
21%
<0.001 
Mostly enough money
24%
25%
Sometimes enough money
12%
31%
29%
Never enough money 8%
18%
Currently employed
58%
44%
<0.001
Homeowner
22%
16%
Renting
50%
60%
67%
Unstable/ Other 6%
17%
University
39%
34%
High supportive network#
59%
55%
0.263
Medium support
33%
32%
Low support
10% 9%
13%
Living with partner
42%
Partner, not living together
14%
20%
23%
No Partner
45%
Depression★ (PHQ-9)
0.004
Temporary accommodation, staying with family or friends, homeless, other; #Modified Duke Functional Social Support Questionnaire (FSSQ); ★ Major/Other depression by PHQ-9.
*chi squared test

10. Baseline characteristics: MSM, MSW, women On ART started > 6 months ago N=2445
MSM N=1678
MSW N=285
Women N=482
*p-value
Enough money for basic needs
53%
27%
21%
<0.001 
Mostly enough money
24%
25%
Sometimes enough money
12%
31%
29%
Never enough money 8%
18%
Currently employed
58%
44%
<0.001
Homeowner
22%
16%
Renting
50%
60%
67%
Unstable/ Other 6%
17%
University
39%
34%
High supportive network#
59%
55%
0.263
Medium support
33%
32%
Low support
10% 9%
13%
Living with partner
42%
Partner, not living together
14%
20%
23%
No Partner
45%
Depression★ (PHQ-9)
0.004
Temporary accommodation, staying with family or friends, homeless, other; #Modified Duke Functional Social Support Questionnaire (FSSQ); ★ Major/Other depression by PHQ-9.
*chi squared test

11. Baseline characteristics: MSM, MSW, women On ART started > 6 months ago N=2445
MSM N=1678
MSW N=285
Women N=482
*p-value
Enough money for basic needs
53%
27%
21%
<0.001 
Mostly enough money
24%
25%
Sometimes enough money
12%
31%
29%
Never enough money 8%
18%
Currently employed
58%
44%
<0.001
Homeowner
22%
16%
Renting
50%
60%
67%
Unstable/ Other 6%
17%
University
39%
34%
High supportive network#
59%
55%
0.263
Medium support
33%
32%
Low support
10% 9%
13%
Living with partner
42%
Partner, not living together
14%
20%
23%
No Partner
45%
Depression★ (PHQ-9)
0.004
Temporary accommodation, staying with family or friends, homeless, other; #Modified Duke Functional Social Support Questionnaire (FSSQ); ★ Major/Other depression by PHQ-9.
*chi squared test

12. Cross sectional analysis: on ART > 6 months and factors associated with VL> 50 c/ml
p=0.003♯
p<0.001
% with VL>50 copies/ml
♯ Chi squared tests

13. Cross sectional analysis: on ART 6 months: socioeconomic factors associated with VL> 50
p<0.001♯
p<0.001
p=0.005
p=0.15
p=0.046
% with VL>50 copies/ml
♯p values by Chi squared tests

14. Prevalence ratios from modified Poisson regression
Cross sectional analysis: comparing VL>50 c/ml in MSM to MSW and women
Women
MSW
MSM
p=0.008
p=0.013
p=0.045
p=0.24
p=0.007
p=0.17
p=0.023
p=0.23
Unadjusted
Adjusted for age and UK birth/ English fluency
Adjusted age and financial hardship
Adjusted for age and employment
Adjusted for age and housing status
Adjusted for age and education
Adjusted for age, socioeconomic factors,
partner, supportive network and depression
Adjusted for age only
Prevalence ratios from modified Poisson regression

15. Longitudinal analysis: VL rebound (first VL >200c/mL) during follow-up
N=1586 with VL<50c/mL on ART, started ≥6 months ago#
Women N=271
MSW N=163
MSM N=1152
Number with VL>200c/mL during follow-up 24 19 43
Person-years at risk
406
241
1929
Rebound rate* /100 p-y
[95% CI]
5.9
[3.7, 8.8]
7.9
[4.8, 12.3]
2.2
[1.6, 3.0]
p<0.001 for comparison across gender/sexuality groups
* First VL>200c/mL after questionnaire date.
Mean (range) follow-up from questionnaire 20 months (range 0.1 to 37 months)
#Includes only participants with linked clinic follow-up VL data

16. Hazard ratios by Cox PH regression
Longitudinal analysis: comparing first VL>200 c/ml in MSM to MSW and women
p<0.001
p=0.008
Hazard ratios by Cox PH regression

17. Conclusions and Recommendations
In the ASTRA study, MSW and women compared to MSM more likely to have: -detectable viral load -viral load rebound after suppression Differences in virological outcomes between MSM and women are largely explained by socio-economic circumstances They appear to have less impact for virological differences between MSM and MSW Interventions aiming at assisting those at socioeconomic disadvantage may improve viral load outcomes in women and to some extent MSW Researchers should encourage equity of access and participation Clinical research should include measures of socioeconomic factors

18. Acknowledgments Thank you to all ASTRA study participants
ASTRA clinic teams
Royal Free Hospital: Alison Rodger; Margaret Johnson; Jeff McDonnell; AdebiyiAderonke
Mortimer Market Centre: Richard Gilson; Simon Edwards; Lewis Haddow; Simon Gilson; Christina Broussard; Robert Pralat; SonaliWayal
Brighton and Sussex University Hospital: Martin Fisher; Nicky Perry; Alex Pollard; Serge Fedele; Louise Kerr; Lisa Heald; Wendy Hadley; Kerry Hobbs; Julia Williams; ElaneyYoussef; Celia Richardson; Sean Groth
North Manchester General Hospital: Ed Wilkins; Yvonne Clowes; Jennifer Cullie; Cynthia Murphy; Christina Martin; Valerie George; Andrew Thompson
HomertonUniversity Hospital: Jane Anderson; SifisoMguni; DamilolaAwosika; Rosalind Scourse
East Sussex Sexual Health Clinic: KazeemAderogba; Caron Osborne; Sue Cross; Jacqueline Whinney; Martin Jones
Newham University Hospital: Rebecca O’Connell; Cheryl Tawana
Whipps Cross University Hospital: Monica Lascar; ZandileMaseko; Gemma Townsend; Vera Theodore; Jas Sagoo
ASTRA core team: Fiona Lampe; Alison Rodger; Andrew Speakman; Andrew Phillips
ASTRA data management: Andrew Speakman; Marina Daskalopoulou; Fiona Lampe
ASTRA advisory group: Lorraine Sherr; Simon Collins; Jonathan Elford; Alec Miners; Anne Johnson; Graham Hart; Anna-Maria Geretti; Bill Burman
CAPRA grant Advisory Board: Nick Partridge; Kay Orton; Anthony Nardone; Ann Sullivan
The ASTRA study presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (RP-PG ). The views expressed in this presentation are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health