Factors associated with antiretroviral therapy adherence in adults: an integrative review of literature

Abstract

AIDS is an advanced clinical manifestation of HIV infection. It generates severe immunodeficiency and associated infections that may lead to death. The antiretroviral therapy (ART) has reduced the morbimortality of HIV/AIDS, but its benefits depend on ART adherence. This integrative review followed the PICO method to identify factors associated with adult adherence to ART. Empirical papers published between January 2010 and December 2016 in the Medline, SciELO, Lilacs and PePSIC databases were included. We analyzed 125 papers regarding the characteristics of studies, adherence measures and associated factors. Results showed a wide variety in the definition of adherence and the use of measures for its monitoring, as well as several adherence-associated factors. These were categorized as follows: 1- Individual variables; 2- Treatment characteristics; 3- HIV/aids infection characteristics; 4- Relationship with the health services; 5- Social support. Health services should characterize the users’ profiles, systematize adherence measures and regionally assess adherence-associated factors for the early detection of non-adherence to ART and implementation of effective intervention plans.

HIV; AIDS; Antiretroviral therapy; Medication adherence

Resumo

A AIDS é uma manifestação clínica avançada da infecção pelo HIV. Gera imunodeficiência grave e inúmeras infecções associadas, podendo levar à morte. A disponibilidade da Terapia Antirretroviral (TARV) diminuiu a morbi-mortalidade do HIV/AIDS, mas seus benefícios dependem da adesão ao tratamento. Esta revisão integrativa da literatura seguiu a estratégia PICO para identificar os fatores associados à adesão à TARV em adultos. Foram consultadas as bases Medline, SciELO, Lilacs e PePSIC e incluídos artigos publicados entre janeiro de 2010 e dezembro de 2016. Foram analisados 125 artigos, quanto às características dos estudos, medidas de adesão e fatores associados. Os resultados mostraram grande variação na definição da adesão e no uso das medidas para seu monitoramento, além de inúmeros fatores associados à adesão. Os quais foram agrupados nas categorias: 1. variáveis individuais; 2. características do tratamento; 3. características da infecção pelo HIV/AIDS; 4. relação com o serviço de saúde e 5. apoio social. É importante que os serviços caracterizem o perfil dos usuários, sistematizem as medidas de adesão e avaliem regionalmente fatores associados à adesão, para a detecção precoce da não adesão à TARV e estabelecimento de planos efetivos de intervenção.

HIV; AIDS; Terapia antirretroviral; Adesão à medicação

Introduction

The Acquired Immunodeficiency Syndrome (AIDS) emerged as a new nosological entity in the early 1980s. It is an advanced clinical manifestation of Human Immunodeficiency Virus (HIV) infection that generates severe immunodeficiency and can lead to the emergence of infections and associated neoplasms, and eventually death¹.

Due to its pandemic nature and severity, AIDS is a major global public health issue. Over the last decades, the availability of antiretroviral drugs (ARVs) has led to a significant decrease in HIV/AIDS-related morbimortality and increased quality of life of people living with the disease. The introduction of antiretroviral therapy (ART) has developed the potential of transforming AIDS into a chronic disease with possibilities for control. However, HIV/AIDS still has no cure and the effectiveness of treatment necessarily depends on lifetime adherence to ART².

In 2015, approximately 36.7 million people were infected with the HIV virus and 17 million had access to treatment³. Between 1980, onset of the epidemic in Brazil, and June 2016, 842,710 HIV/AIDS cases were registered in the country. In recent years, Brazil has reported an increased detection rate of AIDS cases among young people aged 15-24 years⁴.

The initial goal of ART is not only to achieve, but also to keep viral load at undetectable levels⁵-⁷. Polejack and Seidl² point out that among the strategies to combat the epidemic worldwide, the Brazilian program for the universal and free distribution of ARVs to HIV patients, which has been in existence since 1996, under Law Nº 9.113/96⁸, stands out.

Historically, in 1986, the US Food and Drug Administration approved Zidovudine for the treatment of AIDS. In Brazil, this drug was distributed in 1991. During this period, ART was based on the use of only one type of medication. As research developed further, new drugs emerged, expanding treatment options. Between 1993 and 1994, the first studies on the combination of drugs, dual ART and then triple ART became the world standard in 1996⁹.

Triple ART is also known as Potent Antiretroviral Therapy or Highly Effective Antiretroviral Therapy. It is generally composed of two classes of drugs, which are separated according to their action, namely: nucleoside/nucleotide reverse transcriptase inhibitors (NRTI); non-nucleoside reverse transcriptase inhibitors (NNRTIs); protease inhibitors (PI); fusion inhibitors and integrase inhibitors¹,¹⁰.

In December 2013, Brazil became the first developing country and the third in the world to recommend the immediate onset of ART for all PLWHA regardless of CD4 count and viral load¹¹. The country also undertook with the United Nations a commitment to the 90-90-90 goals, by which countries must achieve 90% of diagnosed PLWHA, 90% of PLWHA diagnosed for ART and 90% of PLWHA receiving ART with viral suppression¹¹ by 2020.

To achieve these goals, treatment adherence is necessary. Adherence to ART is a dynamic, multi-determined process under the responsibility of patients², with typical characteristics according to each age group¹², and the health team⁵,⁶. This is a complex issue, permeated by the relationship of trust and linkage between the health team and the service user⁵.

Adherence to a drug involves its uptake at the prescribed dose and frequency¹⁰, but there is no consensus as to definitions of good and poor adherence⁶. Early adherence studies described that at least 95% adherence to ART would be necessary to keep HIV viral load undetectable¹³. Glass and Cavassini⁷ indicated that potent ART regimens can keep viral suppression at adherence rates below 95%. However, Rocha et al⁶ point out that most studies on the subject consider that there is adherence when PLWHA use 80 to 100% of the prescribed doses.

Just as frequency of use does not count on consensus, there are many ways to verify adherence. The most commonly used methods include indirect measures, such as self-report, electronic medication monitoring, pill counts and drug withdrawal records. One direct measure is detecting ARVs or their metabolizers in the blood stream²,⁵,⁶.

Adherence is one of the main variables in which health services can intervene to increase the effectiveness of HIV/AIDS treatment, but there are still several challenges related to this issue²,¹¹. Considering its importance, it is understood that systematization of already identified factors associated with adherence is useful for reflecting on strategies for its implementation. Thus, this integrative review aims to identify in the literature factors associated with adult adherence to ART, considering the 2010-2016 period.

Methodology

Type of study

This is an integrative literature review aimed at synthesizing the state of knowledge related to a given subject and pointing out possible gaps that require further research¹⁴.The research question of this study was defined based on the PICO strategy, which provides for the definition of the participant (P), intervention (I), comparison (C) and outcome(s) (O)¹⁵. We intend to answer the guiding question: What factors identified in the literature (O) are associated with adherence to ART (I) in adults living with HIV/AIDS (P)?

Paper selection course

Papers were selected in April 2016 for the period 2010-April 2016, and in May 2017, for the year 2016. Two independent referees conducted this search. A third referee assessed any disagreement among reviewers regarding study suitability. We searched the National Library of Medicine (Medline) via the Virtual Health Library (BVS), Latin American and Caribbean Literature in Health Sciences (Lilacs), Scientific Electronic Library Online (SciELO) and Electronic Periodicals of Psychology (PePSIC) databases. We considered Portuguese, English and Spanish papers published in the period January 2010-December 2016.

In the Lilacs, SciELO and PePSIC databases, the term “adherence” was cross-referenced with the following descriptors: HIV, AIDS, acquired immunodeficiency syndrome, high activity antiretroviral therapy, antiretroviral therapy, antiretroviral therapy and factors, and in these databases, the English and Spanish versions of the chosen terms were also searched each one at a time. In the Medline search process, due to the characteristics of this database, only English descriptors were used.

The inclusion criteria established for the selection of papers were: 1. Empirical papers that identified factors associated with ART adherence; 2. Published in English, Spanish or Portuguese; 3. That used a quantitative approach, 4. Made with PLWH with age group from 18 years and over; and 5. That were freely available for full-text reading on the Internet.

Exclusion criteria were defined as: 1. Literature review papers; 2. Theoretical studies, case reports, dissertations, theses, book chapters, consensuses, supplements or editor’s comments; 3. Studies evaluating adherence interventions/strategies, programs, services and public policies related to ART adherence; 4. Works on the development and validation of scientific tools; 5. Studies addressing adherence to ART in children and adolescents living with HIV/AIDS, due to the peculiarities of access conditions to ART and typical characteristics of this age group, and 6. Studies addressing vertical HIV transmission and adherence to ART in pregnant women and postpartum women living with HIV/AIDS, due to ART’s peculiarity.

To verify whether papers met the inclusion and exclusion criteria, an evaluation was performed by two independent reviewers, in the following order: (1) titles of all identified studies; (2) abstracts of selected studies in the previous phase; and (3) full-text reading of selected texts. After exclusion of papers that did not meet the inclusion criteria, a list of all the papers that composed the corpus of analysis of this study was drawn, with the following data: year and place of publication, study design, sample size, adherence measures used, levels of adherence and main factors associated with adherence.

Results

In all, 2,492 titles were identified. The database with the highest number of papers was Medline (1,528), followed by SciELO (676), Lilacs (249) and PePSIC (39). Initially, 490 studies were excluded because they were duplicated. Then, 1,675 paper were excluded, mainly because studies did not address factors associated with ART adherence (1,211). Therefore, 327 articles remained for full-text reading. Of these publications, 164 were retrieved for free full-text reading, and after that reading, 39 publications were excluded, totaling 125 papers that composed the corpus of the work. Figure 1 shows the flowchart of the selection strategy of studies according to PRISMA standards¹⁶.

Figure 1
Flowchart of the selection of studies according to PRISMA.

Characteristics of studies

The year with the highest number of published studies was 2011 (19.2%). Table 1 shows a wide geographical distribution in the developed studies; however, almost half of the studies were conducted in North America (n = 61, 48.8%), of which 56 were in the United States. Thirteen studies were published in Brazil. It is noteworthy that four papers were developed in more than one country¹⁷-²⁰.

Table 1
Distribution of 125 papers analyzed according to selected variables.

Study characteristics	N	%
Year of publication
2010	17	13.6
2011	24	19.2
2012	19	15.2
2013	16	12.8
2014	20	16.0
2015	16	12.8
2016	13	10.4
Location
Africa	22	17.6
North America	61	48.8
Latin America	21	16.8
Asia	11	8.8
Europe	9	7.2
Multi-continental	1	---
Study sampling size
≤ 50 participants	2	1.6
51 to 100 participants	15	12.0
101 to 500 participants	71	56.8
501 to 1,000 participants	15	12.0
1,001 to 10,000 participants	21	16.8
> 10,001 participants	1	---
Design
Cross-sectional	72	57.6
Longitudinal	50	40.0
Case-control	3	2.4
Use of adherence measures
Use of 1 measure	102	81.6
Use of 2 measures	20	16.0
Use of 3 measures	3	2.4
Adherence measures
Self-report	88	70.4
Dispensing at the pharmacy	25	20.0
Tablet counting	19	15.2
Electronic device (MEMS)	17	13.6
Viral load	2	1.6
Recording in medical records	2	1.6
Adherence measure cutoff point
100%	14	11.2
95%	45	36.0
90%	13	10.4
< 90%	3	2.4
Not provided	50	40.0

Regarding sample size, most of the studies (56.8%) were performed with a range of 101 to 500 participants and only 2 (2.6%) had a sample size of less than 50. The survey with the smallest sample size was that of Keuroghlian et al.²¹, with 43 participants, and the survey with the largest sample size was that of Murphy et al.²², with 14,128 participants.

The groups of people who composed the sample varied in the papers analyzed. There was one work with people over 50 years of age²³, one with PLWHA with TB-coinfection²⁴, three with people starting ART²⁵-²⁷, five with illicit drug users²⁸-³², six with women, as in the work of Jones et al.³³, and six with men, exemplified in the study by Knowlton et al.³⁴. Among the studies analyzed, 72 (57.6%) were cross-sectional, as in Silva et al.²⁷, 50 (40%) were longitudinal, including a prospective cohort study, as in Lee et al.³⁰, and retrospective, as in Scott-Sutton et al.³⁵, and three (2.4%) case-control, as in Rego et al.³⁶.

Definition and measures of adhesion

The cutoff point established for adherence ranged from 75% to 100% of the use of prescribed medication doses, with adherence limited to 95% for 45 (36.0%) reviewed studies. Five studies defined adherence considering different sub-levels³⁵,³⁷-⁴⁰. For example, Kalichman et al.³⁸ considered fair adherence (75% of medication use), good (85%) and optimal (95%). Two studies defined adherence in days of delay in the withdrawal of medication from the pharmacy²⁶,⁴¹.

Some 81.6% of studies used only one method to measure adherence. Among the adherence measures used, most studies used self-report on medication use for a period (70.4%). Studies that used this measure inquired about the use of medication with varying durations, between 24 hours and 9 months. Some papers chose to use self-report in different periods of time in order to reduce memory bias. One of these studies was that of Lehavot et al.⁴², who evaluated adherence considering 2 weeks and 3, 6 and 9 months, assessed with the Simplified Medication Adherence Questionnaire (SMAQ). While study by Dagli-Hernandez et al.⁴³ used two self-report measures, namely, SMAQ and CEAT-HIV ART Adherence Assessment Questionnaire.

Among the validated self-report scales and questionnaires, the most used adherence measurement tools were the Adults AIDS Clinical Trials Group (n = 17), used in the research by Bianco et al.²³, followed by the Visual Analogue Scale (VAS) (n = 13), used by Murphy et al.²², CEAT-HIV (n = 7), used by Dagli-Hernandez et al.⁴³ and SMAQ (n = 6), used by Knowlton et al.³⁴. The Center for Adherence Support Evaluation Index, used by Morojele et al.⁴⁴ and the Morisky Medication Adherence Scale, used for example by Kader et al.⁴⁵ were used in three studies each. The Questionnaire on Psychological Variables and Adherence Behaviors (VPAD-21) was used only in one study⁴⁶.

The second most commonly used measure of adherence was the pharmacy dispensing record (n = 25, 20%), used by Fonseca et al⁴¹, followed by tablet count (n = 19, 15.2%), employed, for example, by Yaya et al.⁴⁷ and by the electronic medication monitoring device. This device is placed on the medication’s bottle cap and was used in 17 surveys, such as that of Knowlton et al.³⁴, all conducted in the U.S. Other measures included undetectable viral load (n = 2), used by Dagli-Hernandez et al.⁴³ and medical record (n=2), used by Silva et al.²⁷.

Twenty-three studies (18.4%) used more than one adherence measure, but with some variations. An example was that of Silva et al.²⁷, who used data collected in medical records and records at the pharmacy as adherence measures. While study by Yaya et al.⁴⁷ assessed adherence using self-report, pill counts and prescription renewal rates for three months.

Level of adherence

Among the studies analyzed, 68.8% showed the level of adherence. The lowest adherence was 20%, identified in the study by Cedillo et al.⁴⁸. This work was conducted in Mexico and examined the relationship between some mental diseases indicators and therapeutic adherence. The highest adherence level was reported by Sumari-de-Boer et al.⁴⁹ with ethnic minorities in the Netherlands and Dutch immigrants, assessing adherence through self-report and pharmacy dispensing. According to the self-report measure, authors observed an adherence of 96% for immigrants and 99% for ethnic minorities, while pharmacy dispensing showed 89% adherence of immigrants and 95% among ethnic minorities.

The level of adherence varies between countries. For example, an adherence rate of 78.4% was found in Togo⁴⁷, while in the U.S., Knowlton et al³⁴ reported an adherence rate of 83%. This variation was observed even within the same country, as seen in different studies carried out in Mexico, where rates of 20%⁴⁸, 47%⁵⁰ and 68% adherence were observed⁴⁶.

Adherence-associated factors

Around 64.8% of studies sought to explore the relationship of a single factor with adherence, while the remainder aimed to identify multiple factors related to adherence. Variables associated to adherence were grouped into five categories, based on the main results of the 125 papers analyzed, namely: 1. Individual variables; 2. Treatment characteristics; 3. Characteristics of HIV/AIDS infection; 4. Relationship with health services; and 5. Social support. These factors are summarized in Table 2, which also contains examples of studies that addressed the referred factors investigated. We reiterate that papers quoted as examples may have other important results, in addition to the underscored.

Table 2
Categories and variables associated with ART adherence.

Categories and variables	Sample examples	Frequency (n) of the variable in the results of papers analyzed
1. Individual characteristics
Sociodemographic characteristics	Bonolo et al. (2013)25; Simoni et al. (2012)53.
Gender		12
Skin color/ethnicity/demographic group		11
Age		10
Schooling		7
Employment relationship/income/economic level		5
Marital status		3
Housing		2
Food insecurity		5
Syndemia		2
Use of licit drugs	Rego et al. (2011)7.	18
Use of illicit drugs	Blashill et al.(2012)31.	9
Negative psychological variables	Cedillo et al.(2011)48.	25
Positive psychological variables	Nokes et al. (2014)17.	15
Neuropsychological aspects	Kelly C.M. et al. (2014)54.	6
Lifestyle	Tran B et al.(2013)55.	5
Spirituality and religiosity	Kisenyi et al.(2013)56.	3
2. Antiretroviral treatment	Langebeek et al.(2014)18; Scott- Sutton et al.(2016)35.
Medication scheme		13
Adverse effects		12
Forgetfulness, being away from home and sleeping at the time of medication		9
Time of use of ART		7
Lack of ART		2
Strategy to remember ART		2
ART cost		1
Time between first ART and HIV diagnosis		1
3.HIV/AIDS infection	Wilson et al.(2013)57; Nelsen et al. (2013)58.
Diagnosis time		5
General health conditions		5
Other people know about the diagnosis		3
Knowledge about HIV and ART		2
Having a family member with HIV		1
4. Health services	Murphy et al.(2012)22.
Multidisciplinary team available		1
Receiving home visits		1
Time interval between consultations		1
Distance from consultation location		1
Specialized pharmacies		1
Care satisfaction		1
Relationship between professionals and users of health services		2
5. Social support	Kelly J.D. et al. (2014)59.	9

Individual variables

This category included variables related to participant characterization factors, such as age, gender, skin color/ethnicity/demographic group, schooling, employment status, income, marital status, housing, food insecurity and syndemia i.e. multiple interconnections between health and psychosocial conditions. Also included are lifestyle (use of vitamin C, physical exercise, quality of sleep and use of cellphone reminders), neuropsychological aspects and spirituality and religiosity, considering spirituality as an existential intimate feeling of search for the meaning of life and being in the world and religiosity as a set of beliefs and practices belonging to a doctrine, shared by a group of people⁵¹.

The influence of gender is highlighted, showing contradictory relationships. For example, some studies have indicated that women would have lower adherence³², while others indicated that being a man would be a factor of low adherence⁵². Skin color/ethnicity/demographic group was also frequently associated with adherence. In the reviewed studies, the skin color black⁵³ and low income were associated with low compliance⁵³.

Individual variables also include factors related to the use of licit drugs (alcohol, amphetamines, drugs and tobacco abuse) and use of illicit drugs. It is worth mentioning the use of alcohol, which was cited as a relevant predictor of non-adherence in 14 studies, such as Rego et al.³⁶.

Psychological variables also appeared as a significant factor associated with adherence, and are divided into negative psychological variables, which were predictors of low adherence, and positive, which facilitated adherence. Among negative variables are psychic distress, anxiety, stress, suffering violence and evidence of depressive, panic, posttraumatic stress disorders and pain catastrophization. Positive psychological variables include self-efficacy, attitude/motivation, personal beliefs, coping/resilience and quality of life.

Antiretroviral treatment

Among the variables related to antiretroviral treatment, the following are indicated: medication regimen; adverse effects; forgetfulness, being away from home; sleeping at the time of medication; time of ART use; lack of ART; strategy to remember ART; time between first ART and the diagnosis of HIV and the cost of ART. The simplification of ART, that is, reduced number of pills resulted in improved adherence¹⁸, and there was greater adherence in single pill use compared to the same regimen more than once per day⁶⁰.

HIV/AIDS infection

Among the variables related to HIV/AIDS, the factors associated with adherence were: time of diagnosis; general health conditions, both good and bad; dissemination of the serological status, that is, other people know about the retrovirus diagnosis; knowledge about HIV and ART and having family members living with HIV. We can observe that there were studies in which the longest time of diagnosis was related to better adherence rates⁶¹, while in other studies adherence decreased over the time of diagnosis of HIV/AIDS⁵⁷, which shows that adherence can have different relationships with the same variable, depending on the population surveyed.

Health services

In relation to health services, the availability of a multidisciplinary team, receiving home visits, shorter time interval between consultations, shorter distance from the consultation site, availability of specialized pharmacies, satisfaction with care and good relationship between professionals and users of health services, with emphasis on quality of the therapeutic relationship and agreement between doctor/patient were associated with better adherence rates. These results point to the importance of a multidisciplinary and medical team integrated in the services of reference for early detection of non-adherence⁵.

Social support

In this review, social and family support was a significant factor associated with adherence to ART. This factor was investigated in studies such as Kelly et al.⁵⁹. Social and affective support was pointed out as a means to improve adherence, although it is not enough to ensure a successful treatment, requiring a combination of multiple factors⁵⁹.

Discussion

This integrative literature review pointed out that non-adherence occurs universally and is observed in both developed and developing countries. It also showed that adherence might vary within the same country or from one region to another, evidencing the heterogeneous aspect of HIV/AIDS infection, adherence to ART and associated factors. According to results, non-adherence rates ranged from 1% to 80%⁴⁸,⁴⁹.

Among the measures of adherence, the use of single (81.6%) and subjective measures predominated, since 70.4% of the studies used self-report. Self-report’s advantages are low cost and short application time⁴³. However, its use raises some questions, considering that its results tend to be less accurate⁴³. According to Polejack and Seidl², the wide variety of methods for assessing adherence according to self-report may hinder the comparison of outcomes between surveys. In their study, Dagli-Hernandez et al.⁴³ evaluated which indirect adherence evaluation method better reflects ART’s effectiveness, comparing three adherence measuring methods, namely, viral load, pharmacy drug dispensing and two measures of validated self-report (SMAQ and CEAT-HIV). This research suggested the combination of two gauging methods as the best way to assess adherence and recommended the use of the viral load test and the CEAT-HIV adherence questionnaire.

The use of 7 validated self-report scales / questionnaires were observed, which indicates a progress, since the use of validated tools allows a better comparison of results and more reliable data. It should be noted that electronic monitoring is still uncommon in developing countries, a fact that has already been observed in the reviews of Bonolo et al.⁵ and Rocha et al.⁶², and can be explained by the high cost of this tool.

A great variability of the levels of adherence found are noted, mainly due to the definition of adherence, type of measurement and cut-off point. According to the established adherence cutoff point, it varied between 75% and 100% of the use of the prescribed medication doses. Given this variability, it is difficult to interpret whether adherence depends on the population studied or whether it is related to the great methodological distinction of the studies. Thus, the definition of a single adherence measure, composed of two measurement methods, could increase the comparability of the studies and ensure measure’s reliability.

In this study, multiple factors associated with ART adherence were identified through individual variables, treatment characteristics, characteristics of the infection, aspects of the relationship with health services and social support. It is worth noting that, in view of these variables, adherence assumed different values and relationships, depending on the population studied⁵⁷,⁶¹, confirming the heterogeneous and regional character of adherence-related factors.

It is important to highlight that individual variables related to the person under treatment, which is inserted in a socio-historical and cultural context. Thus, these variables are traversed by sociocultural issues. Within this category, sociodemographic factors⁵³ were important predictors of non-adherence, showing association of low adherence with greater social vulnerability⁵³. Ayres et al.⁶³ say that social vulnerability expresses a set of individual, collective and contextual illness-predisposing aspects. Such predisposition stems from reduced access to adequate resources to protect themselves. This realm of ART adherence deserves a close look of national and international pandemic public policy programs.

Also in the individual variable category, a gap was identified in the studies on adherence with specific populations. We found only one study with the elderly and no studies with young adults. In this context, it is worth noting that, in Brazil, the rate of HIV/AIDS detection has increased in this age group⁴. Likewise, studies on adherence with heterosexuals and men who have sex with other men were found, but no research was found on adherence to treatment with women who have sex with other women. Pinto et al.⁶⁴ point out the scarce volume of studies on sexual risk behavior in lesbians and reiterates that, while there is a low risk of HIV transmission among women who have sex with other women, the possibility is there and transmission can occur with the exchange of vaginal secretions, through the practice of sex during the menstrual period, as well as through shared unprotected sexual accessories.

It is also worth noting that the use of cell phone reminders has been associated with better adherence rates⁵⁵. In this review, this variable was included in lifestyle, although it should be considered that in many countries and for many people, having a cell phone is not an option, due to its high cost. Nevertheless, many interventions have been studied with the use of mobile communication technologies to support adherence, as in the study by Rodrigo et al.⁶⁵ carried out in Indiato analyze the cost of this type of intervention, in which it was concluded that the cost is low and is facilitated by the low cost of mobile communication in the country. The importance of critical reviews and empirical studies on interventions and strategies to improve antiretroviral adherence rates is underscored.

In the category of ART, studies have shown that the simplified antiretroviral regimens with a single tablet favored adherence¹⁸,³⁵. However, while Brazil has been distributing the combined triple scheme in a single drug since 2014¹⁰, in this review, no studies with this theme were found in the country.

The review did not include all existing databases and did not investigate adherence in children and adolescents or in pregnant and postpartum women. Nevertheless, studies analyzed suggest the importance of constant monitoring and evaluation of adherence to ART, its associated factors and offering comprehensive care to PLWHA. The early detection of non-adherence allows the establishment of timely interventions, increasing the quality of life of this population.

Final considerations

The literature review allowed the identification of multiple factors associated with adherence, pointing to the complexity of the issue and the need for constant investigations in this area, taking into account its socio-historical and cultural realms. In addition to affecting individual health, adherence to ART is associated with the potential collective transmission of HIV/AIDS infection. Critical reviews and empirical studies on interventions and strategies to improve adherence could overly contribute to academic and technical areas, as well as to the population in general, due to the importance of early detection of the risk of non-adherence and of establishing individual and collective care strategies for PLWHA according to the demands and needs of the users of each service.

The analysis of papers showed that it is necessary to concentrate actions to identify the levels of adherence in different countries, including in the investigations the identification of adherence-associated factors. These factors vary across different regions, and it is necessary to consider the characteristics of people with HIV/AIDS, the treatment they receive, the services they attend and the emotional and social support they receive. Moreover, the difficulty of comparing study results due to methodological differences reveals the need for the definition of a gold standard measure for adherence, allowing a comparison of the prevalence identified in different investigations and regions/countries.

Based on these considerations, we highlight the importance of health services in their work of characterizing the profile, knowing the factors associated with the adherence of its users and systematizing measures that favor adherence. Investments are urgently required in public policies focused on adherence to ART, ranging from the training of health teams and services infrastructure to social security actions that benefit the entire population, including health, education, housing and fight against HIV/AIDS prejudice and stigma related to the infection.

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Publication Dates

• Publication in this collection
  22 July 2019
• Date of issue
  July 2019

History

• Received
  24 July 2017
• Accepted
  19 Oct 2017
• Reviewed
  21 Oct 2017