Adherence to antiretroviral therapy among people living with HIV/AIDS in northeastern Brazil: a cross-sectional study

ABSTRACT BACKGROUND: Nonadherence to antiretroviral therapy (ART) may lead to viral replication and development of antiretroviral resistance. OBJECTIVE: To identify the factors associated with nonadherence to ART among people living with the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) (PLWHA). DESIGN AND SETTING: Cross-sectional study in a tertiary-level hospital in northeastern Brazil. METHODS: Intake of less than 90% of the antiretroviral drugs prescribed in the last week prior to the interview was defined as nonadherence. Intake was evaluated using a questionnaire. Descriptive and multivariate analyses were conducted on the study population, with estimation of the respective odds ratios and 95% confidence intervals. RESULTS: The prevalence of nonadherence was 28.4%. Significant associations were found regarding the following variables: age less than 35 years, smoking, sedentary lifestyle, lack of medication and lack of knowledge regarding the patient’s HIV status, on the part of the patient’s partner or family. CONCLUSIONS: Encouragement of adherence to antiretroviral therapy is one of the fundamental pillars of treatment for HIV-infected patients. The high proportion of nonadherence (28.4%) and the predictive factors related to this indicate that it is necessary to improve patients’ adherence to antiretroviral therapy.


INTRODUCTION
Antiretroviral therapy (ART) decreases the viral load of the human immunodeficiency virus (HIV) or even renders it undetectable. 1,2 However, problems relating to adherence to this therapy are practically universal, and adherence is a complex process that requires a multifaceted approach for its improvement. 3 Nonadherence to antiretroviral drugs may consequently lead to development of viral resistance, which results in increased viral replication and development of opportunistic infections and other diseases, thereby increasing the morbidity and mortality associated with HIV infection. 4 The ART adherence rates in Brazil vary from 20% to 84%. [5][6][7][8][9] However, the way in which this adherence to therapy is measured differs between studies. In a meta-analysis on ART adherence rates in Latin American and Caribbean countries, Costa et al. 10 found that they varied according to the length of time over which the measurement was made. Thus, individuals' adherence was found to be inversely proportional to the duration of the measurement period. Data regarding adherence obtained through self-reporting has been identified as more reliable than data obtained through medical evaluation. 11 Moreover, it has been found that its accuracy can be amplified through use of questions that are less direct and with absence of prejudgment. 12 Several factors have been correlated with nonadherence to ART among HIV-infected patients.
Pinheiro et al. 13 found that elderly patients had a higher adherence rate and, consequently, that a higher proportion of these patients had an undetectable viral load. Additionally, nonadherence has been correlated with use of illicit drugs, 14 virological failure but also reduces HIV resistance to antiretrovirals (ARVs). 19 Although several studies have been conducted in Brazil regarding ART adherence in the northeastern region of this country, more data is still needed, in order to broaden the notions about this issue and, thus, to enable creation of strategies elaborated on the basis of acquired knowledge.

OBJECTIVES
The aim of this study was to identify the predictive factors that might define the profile of individuals at the highest risk of interruption of treatment, at a large HIV/AIDS treatment center in the northeastern region of Brazil.

Study design and population
This was a cross-sectional study that investigated nonadherence

Adherence to antiretroviral therapy and variables analyzed
The interview data were recorded in a questionnaire that had been elaborated in a previous study. 5 Nonadherence was defined as intake of less than 90% of the medications prescribed in the last week, considering the number of pills taken by asking the patients and the timetable for each intake. 5,21 The outcome variable of this study was characterized as nonadherence in the week prior to the interview (self-reported). The independent variables were of three types, as follows: Adults living with HIV can expect to gain many benefits from aerobic exercise, with improved cardiorespiratory function and psychological health. 26 Thus, the association between practicing exercise and adherence to therapy may be related to a possible improvement of psychological health, thereby leading to self-care.
This conclusion has been confirmed through the observation that depressed patients or patients with other psychological disorders have less adherence to ARVs. 17,27 The association between nonadherence and the variable of lack of knowledge among partners and relatives of the subject's HIV serological status may be related to social isolation. This is a common phenomenon among HIV-infected individuals and is caused by fear of social stigma. Hence, maintaining confidentiality seems to be the most adequate solution. 28

CONCLUSIONS
This study showed that the prevalence of nonadherence was 28.4% and that the following factors presented statistical associations with it: age from 18 to 35 years, smoking, sedentary lifestyle, lack of knowledge among partners and families regarding the patient's serological status, lack of medication and difficulty in consulting a doctor. Identification of factors that are predictive of nonadherence will allow the multidisciplinary teams caring for PLWHA to adopt measures that increase drug adherence and will contribute towards establishment of information for a surveillance system.