Increased risk of virological failure to the first antiretroviral regimen in HIV-infected migrants compared to natives: data from the ICONA cohort

Migrant and Italian HIV-infected patients (n=5773) enrolled in the ICONA cohort in 2004-2014 were compared for disparities in access to an initial antiretroviral regimen and/or risk of virological failure (VF), and determinants of failure were evaluated. Variables associated with initiating antiretroviral therapy (ART) were analyzed. Primary endpoint was time to failure after at least 6 months of ART and (?) defined as: (a) VF, as first of two consecutive viral loads (VL) >200 copies/ml, (b) TD (treatment discontinuation) for any reason, (c) TF (treatment failure) as confirmed VL>200 cp/ml or TD. A Poisson multivariable analysis was performed to control for confounders. Migrants presented significantly lower CD4 counts and more frequent AIDS events at baseline. When adjusting for baseline confounders, migrants presented a lower likelihood to begin ART (OR 0.80, 95% IC 0.67-0.95, p=0.012). After initiating ART, the incidence VF rate was 6.4 per 100 person-years (95%CI 4.8-8.5) in migrants and 2.7 in natives (95%CI 2.2-3.3). Multivariable analysis confirmed that migrants had a higher risk of VF (IRR 1.90, 95%CI 1.25-2.91, p=0.003) and TF (IRR 1.16, 95%CI 1.01-1.33, p=0.031), with no differences for TD. Among migrants, variables associated with VF were age, unemployment and use of a boosted-PI based-regimen vs NNRTIs. Despite the use of more potent and safer drugs in the last ten years, and even in a universal health care setting, migrants living with HIV still present barriers to initiating ART and an increased risk of VF compared to natives.