Quality of life, clinical characteristics and treatment adherence of people living with HIV/AIDS

OBJECTIVES: to assess the quality of life of people living with HIV/AIDS and verify its association with clinical characteristics and treatment adherence. METHOD: cross-sectional study conducted in a hospital in the state of Paraíba, Brazil. A questionnaire was used to collect socio-demographic and clinical data. The quality of life scale proposed by the World Health Organization and a questionnaire to measure treatment adherence were used. RESULTS: of the 314 interviewees, 190 (60.5%) were male, aged 43 years on average, 121 (38.5%) had attended up to five years of schooling, 108 (34.4%) received up to two times the minimum wage, and 112 (35.7%) were on sick leave. In regard to clinical variables, individuals with an undetectable viral load scored higher in all the domains concerning quality of life, with statistically significant differences in three domains. Regarding treatment adherence, 235 (73.8%) presented poor adherence and those who strictly adhered to treatment obtained better scores in quality of life. The results show that quality of life is better among individuals adherent to ART. Supporting people to adhere to the antiretroviral treatment should be a persistent task of healthcare workers and other people participating in the treatment, such as family members and friends.


Introduction
The impact of the antiretroviral therapy (ART) on people with HIV/AIDS contributed to a decrease in mortality or HIV/AIDS-related illnesses among infected people (1) . The number of AIDS-related deaths among adults and children decreased 29% since 2005. A decrease of 37% of AIDS-related deaths was observed in the last decade in Latin America (2) . This decrease in deaths is certainly a result of therapeutic support, which in addition to prolonging survival, also improves quality of life (3) . standards and concerns" (3)(4) .
In this context, the quality of life of people living with HIV/AIDS and its relationship with ART became an object of study. Many studies assess the QoL of these people, however, those addressing the relationship of QoL and ART are rare. Hence, this study's objective was to assess the quality of life of people living with HIV/AIDS and its association with clinical factors and adherence to antiretroviral therapy. and factors influencing treatment adherence (6) . The minimum score is 17 and the maximum score is 89.

Method
In this study, the minimum score was 52 and the maximum was 88. In accordance with the analysis proposed by Remor (6) , the following percentages When the average scores of QoL were analyzed in regard to therapeutic adherence (Table 4), we verified that the individuals classified as "non-adherent" presented the worst scores in all the QoL domains.

Discussion
The socio-demographic characterization found among this study's participants is in agreement with the profile of the HIV/AIDS epidemic in Brazil: men above older than 30 years old, with a low level of education and income, who were infected with HIV/AIDS through sexual transmission (2) .

Changes in the profile of people infected with
HIV have drawn attention. The ratio of cases between men and women decreased in all age groups (7) . Even though the highest incidence of the disease is still observed among male individuals, recent studies show predominance among female individuals. Women are predominant in studies conducted in the South of India (8) and in the United States (9) .
One study developed in India reports that the scores obtained in QoL domains were higher in regard to the environment domain and lower in the domain concerning spirituality (8) . The inverse was observed in for improved QoL (15) .
Spirituality provides support in times of distress, when there is social isolation and distance from the family. Religion is an important aspect providing meaning and order to life, suffering and distress, a result also found in another study (8,16) . An investigation conducted in Ribeirão Preto, SP, Brazil with individuals co-infected with tuberculosis and HIV/AIDS reports that the spirituality domains scored higher than the other domains (17) .
The total score obtained on the CEAT in this study was significantly correlated with the physical, psychological, social relationships, and spirituality/ religion domains. Low scores obtained in the physical domain may be associated with clinical conditions, viral immunosuppression or lack of ART (17) .
Non-adherence to therapy, particularly among people living with HIV/AIDS, is a problem of greater magnitude. The consequences of patients' lack of adherence affect not only the non-adherent individual but also lead to a series of problems that may reach the population in general. Viral suppression, decreased contamination, minimization of opportunistic infections, and reduced resistance to antiretroviral agents depend on therapy adherence (18) .
Most of the studied sample present "poor adherence" and those classified as "non-adherent" obtained the lowest scores in all the QoL domains. The impact of nonadherence to ART on QoL was observed in this study.
Given the changes in mortality and morbidity, studies show the positive impact of adherence to ART on QoL (18) .
It is known that adherence to ART improves clinical results, delays the progression of the disease, which in theory, should improve quality of life (16) . One longitudinal study reports that adherence to ART is associated with improved quality of life (19) . Cross-sectional studies also identified associations between QoL and adherence to ART (10,20) .
When assessing the quality of life of individuals with HIV/AIDS and its association with ART, one needs to identify the individual's clinical characteristics and which phase of the infection the individual is experiencing: the asymptomatic, symptomatic or HIV/AIDS last stage (21) .
Adherence to antiretroviral treatment may cause side effects in the short run (nausea and vomiting) and in the long run (lipodystrophy and dyslipidemia), impacting quality of life. One study reports no significant difference in the domains of QoL in association with the use of antiretroviral agents, but found significant difference in the overall assessment of health with the presence of adverse effects of medications (21) .
The relationship between adherence to ART and quality of life is reciprocal. The quality of life of people living with HIV/AIDS may be influenced by adherence to ART. In this context, it is imperative to understand antiretroviral therapy in order to maximize its benefits and minimize its adverse effects (21) .
Most of the participants in this study were asymptomatic with undetectable viral load (< 50 copies per ml). It can be inferred that these clinical characteristics influence adherence to ART and, consequently, influence the QoL of individuals because the absence of symptoms combined with the presence of undesirable side effects, as reported by another study, are factors that hinder adherence to therapy (22) .
One limitation of this study is the cross-sectional methodological design. Despite this limitation, the results indicate the need to assess the influence of ART on QoL in this specific population.

Conclusion
The quality of life of the studied population according to the WHOQOL HIV Bref was associated with clinical variables and adherence to antiretroviral therapy.
Regarding the clinical variables, it is important to note that individuals with viral load below 50 copies per ml obtained the highest scores in all the QoL domains.
As for adherence to antiretroviral therapy, individuals In this sense, we suggest there is a need to monitor the ART adherence of people living with HIV/AIDS based on the understanding that adherence is a continuous process that mainly involves the family and healthcare workers. In some situations, non-adherence results from the family and the healthcare workers themselves abandoning the patient.