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Educational level and HIV disease progression before and after the introduction of HAART: a cohort study in 989 HIV seroconverters in Spain
  1. Susana Monge1,
  2. Inmaculada Jarrín1,
  3. Santiago Pérez-Hoyos2,
  4. Inmaculada Ferreros3,
  5. Patricia García-Olalla4,
  6. Roberto Muga5,
  7. Jorge Del Romero6,
  8. Josefina Belda7,
  9. Jesús Castilla8,
  10. Francisco Bolúmar9,
  11. Julia Del Amo1,
  12. on behalf of GEMES*
  1. 1National Centre of Epidemiology, Carlos III Health Institute (ISCIII), Madrid, Spain
  2. 2Research Institute, Vall d′Hebrón Hospital, Barcelona, Spain
  3. 3Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
  4. 4Epidemiology Department, Public Health Agency of Barcelona, CIBER, Barcelona, Spain
  5. 5Germans Trias i Pujol University Hospital, Badalona, Spain
  6. 6Centro Sanitario Sandoval. Madrid, Spain
  7. 7CIPS, Alicante, Spain
  8. 8CIBERESP. Navarra PH Institute. Pamplona, Spain
  9. 9University of Alcalá de Henares, Alcalá de Henares, Spain
  1. Correspondence to Dr Julia Del Amo, National Center of Epidemiology (Pab11), Instituto de Salud Carlos III, Av. Monforte de Lemos, 5, Madrid 28029, Spain; jdamo{at}


Objectives To analyse the effect of educational level on the progression from HIV seroconversion to highly active antiretroviral therapy (HAART) requirement, HAART initiation, AIDS and death from any cause at different periods of the HIV epidemic in Spain.

Methods Open, prospective, multicentre cohort of HIV seroconverters set up in 1983. The risk of progression was calculated by the multiple decrements method. Effect of educational level was estimated by Fine and Gray model, adjusting for sex, HIV transmission category, age and method to estimate seroconversion. Calendar period was introduced as a variable that could change over time (<1997; 1997–2003; >2003).

Results Up to 2009, 989 HIV seroconverters with information on educational level were identified. Some 52% and 48% had a low and a high educational level respectively. Persons with higher education had 32% lower risk of death (HR: 0.68; 95% CI 0.45 to 1.03). Regarding progression to AIDS, educational level had no effect in the pre-HAART era (HR: 1.47; 95% CI 0.91 to 2.38), but did show an effect in the period 1997–2003 (HR: 0.58; 95% CI 0.34 to 0.99), which was accentuated after 2004 (HR: 0.26; 95% CI 0.10 to 0.68). No difference was found in time to HAART requirement or initiation.

Conclusions Results suggest that, despite similar access to HAART, persons with low educational level are at increased risk of HIV disease progression, highlighting the impact of social inequities on health. The availability of more effective treatments over time will strengthen the protective effect of higher education on the development of AIDS.

  • HIV
  • AIDS
  • HIV seroconversion
  • disease progression
  • education
  • socioeconomic factors
  • anteretroviral therapy
  • CD4
  • cervicitis
  • chlamydia infection
  • diagnosis
  • anogenital cancer
  • commercial sex
  • epidemiology (general)
  • ethnicity
  • gender
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  • * The following are members of the Spanish Multicenter Study Group of Seroconverters: Santiago Pérez-Hoyos, Inmaculada Ferreros, Julia del Amo, Cristina González, Ana María Caro, Inmaculada Jarrín, Isabel Hurtado, Josefina Belda, Elisa Fernández, Isabel Gómez, Ignacio Alastrue, Concha Santos, Teresa Tasa Zapater, Amparo Juan, Jose Trullen, Robert Muga, Arantza Sanvisens, Jorge del Romero, Paloma Raposo, Carmen Rodríguez, Soledad García, Patricia García de Olalla, Joan Cayla, Eva Masdeu, Rafael Guerrero, Manolo Quintana, Isabel Ruiz, Ramiro Nuñez, Jesús Castilla, Marcela Guevara, Carmen de Mendoza and Natalia Zahonero.

  • Funding This work was supported by FIPSE (Fundación para la investigación y la prevención del SIDA en España, integrated by the Spanish Ministry of Health, Abbott Laboratories, Boehringer Ingelheim, Bristol Myers Squibb, GlaxoSmithKline, Merck Sharp and Dohme and Roche). This work is also supported by RIS (Red de Investigación de SIDA) RD06/006.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Ethics approval was provided by Instituto de Salud Carlos III.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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