Antiretroviral therapy abandonment among adolescents and young people with HIV/AIDS during COVID-19: A case-control study

Objective: to identify the factors associated with antiretroviral therapy abandonment among adolescents and young people living with HIV/AIDS during the COVID-19 pandemic. Method: a case-control study carried out between 2020 and 2021 in Maringá, Paraná. The cases corresponded to the following: adolescents and young people (aged from 10 to 24 years old) diagnosed with HIV/AIDS and who abandoned treatment, while the Control Group consisted of people with similar sociodemographic characteristics, diagnosed with HIV/AIDS and with no history of treatment abandonment. Pairing of the cases and controls was by convenience, with four controls for each case. The research instrument presented sociodemographic variables, clinical characteristics and others, whose association with treatment abandonment was analyzed by means of logistic regression. Results: a total of 27 cases and 109 controls were included in the study (1/4 ratio). The variable associated with an increased chance of abandonment was age close to 22.8 years old (ORadj: 1.47; 95% CI: 1.07-2.13; p=0.024). Sporadic condom use (ORadj: 0.22; 95% CI: 0.07-0.59; p=0.003) and having an opportunistic infection (OR: 0.31; 95% CI: 0.10-0.90; p=0.030) were protective factors. Conclusion: age close to 23 years old at the last consultation was associated with antiretroviral therapy abandonment. The presence of opportunistic infections and condom use are determining factors for treatment continuity during COVID-19.

only cross-sectional and descriptive studies are carried out, which do not produce evidence with high levels of confidence, compromising advances in the area. Therefore, this study is justified by the need to elucidate the complexity involved in the ART abandonment by means of methods that have higher levels of evidence.
In turn, longitudinal studies such as this one are crucial to identify and analyze the intrinsic and extrinsic factors regarding ART abandonment, in addition to producing subsidies for advances in the health care.
The results of this study will assist health professionals, especially nurses, in the elaboration of a comprehensive care plan and ART adherence strategies according to the needs of each adolescent and young person living with HIV/AIDS It is noted that the pandemic period is permeated by challenges for patient safety care and medication availability linked to social isolation. Therefore, the objective of this study was to identify the factors associated with ART abandonment among adolescents and young people living with HIV/AIDS during the COVID-19 pandemic.

Method Study design
A case-control study with a ratio of 1 case/4 controls in adolescent and young. The recommendations set forth in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist (14) were followed to conduct and present the study.

Study locus
The study locus was the Specialized Care Service

Participants
The cases were defined as follows: adolescents and young people (aged between 10 and 24 years old), with the following International Classification of Diseases (ICD) -serves as a basis for identifying statistical trends in mortality and morbidity worldwide -codes referring to HIV/ AIDS: B20.0 to B24, with subsequent ART abandonment.
The controls were defined as adolescents and young people with ICD codes related to HIV/AIDS, undergoing monitoring at the SAE, with no history of ART abandonment.
The following inclusion criteria were considered: being aged between 10 and 24 years old and living in a municipality linked to the 15 th Health Region of the state of Paraná. The exclusion criteria were patients who died (one), transferred to other health services (five) and medical records not identified in the service (three).
It is noted that the expressions "adolescence" and "youth" refer to the age groups from 10 to 19 and from 20 to 24 years old, respectively (15) .

Sample
After an exploratory analysis of the medical records of the prospective participants, the use of the total population was defined in detriment of a sample. Thus, all SAE users were included in the sample, observing the aforementioned selection criteria. The pairing of one (1) case to four (4) controls was for convenience. Thus, four controls (109) were selected for each case (27).
The pairing process took place according to the participants' sociodemographic characteristics, considered as non-modifiable intrinsic factors such as gender, age and abandonment outcome. In addition, the pairing considered the area of residence of the service users, in order to guarantee homogeneity between the groups. Figure 1 presents a flowchart designed to show the selection of the patients.

Bias
The selection bias was addressed using the record numbers of the medical charts, which were checked by two independent researchers.
During data processing, outliers were removed so as to maintain integrity of the database and results, reducing the chance of analysis bias. In addition, the analyses considered missing values as null, removing the participants that did not present all the listed variables, mitigating the action of confounding factors.
The study had its data and results validated by specialists in the method, as a way to avoid interpretation bias. However, the possibility for the occurrence of biases and confounding factors is highlighted, being listed as study limitations.

Data analysis
The data were tabulated in electronic spreadsheets,   The "distance to the service in km" variable, when living more than 17.3 km from the service, remained as a control for the other variables, being associated with ART abandonment, which corroborates another study which showed that living more than 5 km away from the health unit was a predictor of non-adherence to ART (22) .
The interference of geographic access, distance and commute from the patient's home to the health service is a major obstacle, especially as a result of the service offered to people living with HIV/AIDS being centralized in a single physical space (23) . It is important to consider that, along the geographic route, some subjects need a longer period of time to commute to the specialized care service and, consequently, face greater accessibility obstacles for care and access to ART (9) .
It is noted that access to the specialized health care service is an influential factor in adherence to HIV/AIDS care measures and ART, mainly due to its chronicity. As a result, lack of integration with other health services, especially those that are part of Primary Care, associated with the centralization of specialized care, may favor the fragmentation in the development of health promotion and prevention actions and strategies (23) .
The viral suppression probability is related to adherence to consultations and ART, thus improving health results in the long term. However, during the pandemic period, adolescents and young people were vulnerable to interruptions in monitoring and treating the disease.
Social isolation and/or distancing was the main preventive measure during the pandemic; therefore, the interactions with health professionals from the specialized care service, the half-yearly monitoring of CD4 and Viral Load and access to medications for the treatment of HIV and opportunistic diseases were impaired, as many of the patients use public transportation to commute to the health service and, afraid of being contaminated with COVID-19, they ended up not adhering to the treatment (20,24) .
With regard to the epidemiological and behavioral characteristics, in the current study it was identified that occasional condom use is a protective factor for treatment abandonment among adolescents and young people living with HIV/AIDS. A study developed in Uganda identified high rates of young people on ART who are sexually active and occasionally use condoms (25) . In this sense, health professionals need to further strengthen the self-care actions (25,30) , encouraging HIV transmission among peers (7,30) .
It is believed that ART abandonment during the pandemic can also be a reflection of people who still do not fully understand the importance of taking care of themselves and others (25) . However, it is important to consider that, in the context of the study during COVID-19,

Conclusion
Age close to 23 years old at the last consultation was associated with antiretroviral therapy abandonment.