Quality of life, anxiety and depression in patients with HIV/AIDS who present poor adherence to antiretroviral therapy: a cross-sectional study in Salvador, Brazil

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Original

article

Quality

of

life,

anxiety

and

depression

in

patients

with

HIV/AIDS

who

present

poor

adherence

to

antiretroviral

therapy:

a

cross-sectional

study

in

Salvador,

Brazil

Mónica

Narváez

Betancur

_,

_Liliane

_Lins

_,

_Irismar

_Reis

_de

_Oliveira

_,

_Carlos

_Brites

a_{UniversidadeFederaldaBahia(UFBA)ProgramadePós-Graduac¸ãoemMedicinaeSaúde,Salvador,BA,Brazil} b_{UniversidadeFederaldaBahia(UFBA),FaculdadedeMedicina,DepartamentodeMedicina,Salvador,BA,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received12December2016

Accepted17April2017

Availableonline21May2017

Keywords:

Highlyactiveantiretroviraltherapy

HIV/AIDS Adherence Nonadherence Anxiety Depression Qualityoflife

a

b

s

t

r

a

c

t

Theintroductionofhighlyactiveantiretroviraltherapymarkedamajorgaininefficacyof

HIV/AIDStreatmentandareductioninmorbidityandmortalityoftheinfectedpatients.

However,highlevelsofadherencearerequiredtoobtainvirologicsuppression.InBrazil,

thepolicyoffreeanduniversalaccesstoantiretroviraltherapyhasbeeninplacesince1996,

althoughtherearereportsofpooradherence.

Objective:Todefinetheclinical,demographicandpsychologicalcharacteristics,andquality

oflifeofpatientswithHIV/AIDSwhopresentpooradherencetohighlyactiveantiretroviral

therapy.

Methods:Thiswasacross-sectionalstudy.Tobeincludedinthestudypatientshadtobe18

through65yearsold,diagnosedwithHIV/AIDS,havingthetwopreviousviralloadsabove

500copies,asurrogateforpooradherencetoantiretrovirals.Thefollowinginstrumentswere

appliedtoalleligiblepatients:thesociodemographicquestionnaire“AdherenceFollow-up

Questionnaire”,theBeckDepressionInventory(BDI-II),theBeckAnxietyInventory(BAI),

andthe36-ItemShortFormSurvey.

Results:47patientswereevaluated,70.2%werefemale,meanageof41.9years(±10.5),46.8%

weresingle,51.1%self-reportedadherence≥95%,46.8%mentioneddepressionasthemain

reasonfornottakingthemedication,59.5%presentedsymptomsofmoderatetosevere

depression,and44.7%presentedsymptomsofmoderatetosevereanxiety.Finally,regarding

health-relatedqualityoflifethesepatientsobtainedlowscoresinalldimensions,physical

componentsummaryof43.96(±9.64)andmentalcomponentsummaryof33.19(±13.35).

Conclusion: Thepsychologicalcomponentisconsideredtobefundamentalinthe

manage-mentofHIV/AIDSpatients.Psychoeducationshouldbeconductedattheinitialevaluation

to reduce negativebeliefs regarding antiretroviraltherapy Assessment of anxiety and

∗ _{Correspondingauthor.}

E-mailaddress:crbrites@gmail.com(C.Brites).

http://dx.doi.org/10.1016/j.bjid.2017.04.004

1413-8670/©2017SociedadeBrasileiradeInfectologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC

depressionsymptomsshouldbedonethroughouttherapyasbothpsycologicalconditions

areassociatedwithpatientadherence,successoftreatment,andultimatelywithpatients’

qualityoflife.

©2017SociedadeBrasileiradeInfectologia.PublishedbyElsevierEditoraLtda.Thisis

anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

The introduction of highly active antiretroviral therapy

(HAART)inthe1990smarkedamajorgaininHIV/AIDS

treat-ment efficacy,and areductioninmorbidity, mortality,and

qualityoflifeofthesepatients.InBrazil,thepolicyoffreeand

universalaccesstoantiretroviraltherapy1_{hasbeeninplace}

since1996.Currently,therecommendationisforearlyonset

ofHAART,duetothebenefitsforpeoplelivingwithHIV/AIDS

aswellasforviremiacontrol.2,3

However,inorderforHAARTtobesuccessful,adherenceis

crucialandisstrictlyassociatedwithvirologicsuppression.4,5

Therefore,theefficacyofHAARTdependsonmaintaininghigh

ratesoftreatmentadherence,consideredinmostofthe

sci-entificliteratureasadherenceequaltoorgreaterthan95%of

theprescribeddosages.6_{Althoughthemorepotentdrug}

regi-menscurrentlyusedallowformoderateadherencelevels,no

regimenallowsforapartialadherence.7

Lowlevelsofadherence increasedisease progressionas

well as viral resistance, and limit the therapeutic options.

InBrazil,between1999and2008,therewerereportsofpoor

adherencetoHAART,varyingbetween23.3%and36.9%.8–10

Adherence is a complex dynamic and multifactorial

processthatencompassesphysical,psychological,social,

cul-tural, andbehavioral aspects.2 _{Therefore, thereare diverse}

challengesfacedbypeoplelivingwithHIV/AIDS associated

withthedifficultiesinmaintaininghighandprolongedlevels

oftherapeuticadherence.Inpreviousstudiesonthefactors

associatedwithpooradherence,thefollowingwere

empha-sized:depression,anxiety,lowsocialsupport,complexityof

therapeutic regimen, relationship with medical personnel,

lowlevelofschooling,sideeffects,negativebeliefsaboutthe

treatment,stigma,andalcohol/substanceabuse.2,11

In short, the predictive factors of nonadherence may

be grouped as follows: patient characteristics, the

pre-scribedtreatmentregimen,thecharacteristicsofthedisease,

doctor-patientrelationship,andthelocationofmedicalcare

delivery.12,13 _{Thus, the initial challenge for the managers}

ofnationalpolicies and healthcareservices specialized in

HIV/AIDS is tounderstand how all these factors influence

patient adherence, in order to establish effective actions,

adjustedtothepopulationcharacteristics.Furthermore,there

arefewstudiesinBrazilthatevaluatethefactorsassociated

withlowadherenceandthequalityoflifeofpatients

undergo-ingHAART.14,15_{Therefore,themainobjectiveofthisstudywas}

todefinetheclinical-demographicandpsychological

charac-teristicsaswellasqualityoflifeandbeliefsaboutHAARTof

thepatientswhopresentpooradherencetoHAART,and

eval-uatetherelationofsomeofthesecharacteristicstoadherence

andqualityoflife.

Materials

and

methods

Studysetting

This study was conducted atthe Prof. Edgard Santos

Uni-versityHospital(HUPES),Salvador,Bahia,Brazil,areference

center that provides healthcare servicesat theoutpatient

clinicorbyhospitalization,forpatientswithHIV/AIDS

diag-nosis.

Studydesignandpopulation

Thisstudywasacross-sectionalstudy carriedoutbetween

February and May of2016. Patientswith HIV,on

antiretro-viral therapyforatleastoneyear,agedbetween18and 65

years,receiving careatthe AIDS outpatientclinics,having

the last two viral loads above 500 copies, and who could

readandwritewereinvitedtoparticipate.Patientswho

pre-sentedneurocognitiveimpairmentorpsychoticdisturbances

thatcouldcompromisetheirunderstandingofthestudywere

excluded.

Duringthestudyperiod,1395patientswithanHIV/AIDS

diagnosis lookedforcareattheHUPESoutpatientclinic;of

these,898weremaleand497werefemale,andhadtheir

med-icalrecordswerecheckedfortheeligibilitycriteriaconsidered.

Atotalof1331patientsdidnotmeettheinclusioncriteriathus

leaving64patientstobestudied.However,17(26%)patients

refused toparticipateremaining47 (73.4%)tobeevaluated

(Fig.1).

Assessments

Sociodemographiccharacteristics

Astructuredquestionnairewasdevelopedforthestudyaimed

atobtainingtheparticipants’sociodemographicinformation:

gender,age,ethnicity,maritalstatus,sexualorientation,

edu-cation,occupation,andtypesofsupport.Furthermore,they

wereaskedquestionsrelatedtotheirhabitsandhealth

condi-tions,suchasyearofdiagnosisandwhentheybeganHAART,

otherchronicillnesses,alcoholconsumption,useof

psychoac-tivedrugs,andmedicalassistance.Theirmedicalrecordswere

reviewedtoobtaininformationonthemostrecentviralload

andtheCD4+lymphocytecount.

Adherence

Two questionnaires were used to measure adherence: (1)

1395 individuals with HIV/AIDS attended at the HUPES´ AIDS Clinics from February to May 2016

1331 individuals were excluded: 1119 viral load < 500 copies/mL 188 first visit in outpatient clinic 10 unable to read and write 07 psychotic disturbances 05 neurocognitive impairment 02 > 65 years of age

64 elegible individuals

17 individuals refused to participate: 07 were living in the countryside of Bahia 07 lack of interest

02 were working (unable to attend the visits) 01 was participating in another research

47 individuals were included

Fig.1–SummaryoftheselectionprocessofHIV-AIDSpatientspresentingpooradherencetoHIVtherapyinSalvador-Brazil.

Trial Groups(ACTG),16 _{translatedtoPortuguese}17 _toassess

self-reportedadherenceinthepreviousfourdays,useofpills

bydosageandreasonsfornottakingthedrugs;and(2)a

ques-tionnaireon knowledgeand beliefsrelated toAIDS and to

HAART,developedbythesamegroupandtranslatedto

Por-tuguesebyapreviousstudy.18

Adherencewascalculatedasthenumberofdosesthatwere

effectivelytakendividedbythenumberofprescribeddosesin

thepreviousfourdays.Participantswithadherencegreateror

equalto95%wereconsideredasbeingadherent.

Depression

TheBeckDepression InventoryII(BDI-II)inthe Portuguese

version19,20_{wasusedtomeasuredepressionsymptoms.The}

BDI-IIisaself-reportedscalewith21items,eachonewithfour

choicesofanswerthatimplyincreasinglevelsofdepression

severity.Thetotalscoreisthesumoftheindividual scores

oftheitemsandprovidestheclassificationoftheintensityof

depressionasminimal,mild,moderate,orsevere.

Anxiety

TheBeckAnxietyInventory(BAI),Portugueseversion,20

com-prising21 items oranxiety symptomaffirmations that are

evaluatedbythesubjectonascaleoffourpointsrelatedto

thelevelsofincreasingseverityofeachsymptom,wasusedto

assesstheanxietysymptomsofthepatients.Thetotalscore

isthesumoftheindividualscoresoftheitemsandprovides

theclassificationoftheintensitylevelofanxietyasminimal,

mild,moderate,orsevere.

Qualityoflife

To estimate quality of life,the 36-item ShortForm Health

Survey(SF-36),Portugueseversion21_{waschosen.This}

ques-tionnairehas36questionsthatmeasurequalityofliferelated

tohealthineightdimensions:PhysicalFunctioning,Physical

Role,BodilyPain,GeneralHealth,Vitality,SocialFunctioning,

EmotionalRole, andMentalHealth.Furthermore,the

ques-tionnaireallowsforevaluationsofthe physicalcomponent

summaryaswellasthementalcomponentsummary.

Statisticalanalysis

The descriptive analyses of the qualitative variables were

presentedinabsolute andrelative frequencies.Continuous

variables with normaldistribution (age) were presentedas

meanandstandarddeviation.Continuousvariableswithout

normaldistribution(yearssincediagnosis,yearsoftreatment,

numberofpills,viralload,andCD4+lymphocytecount)were

expressed as median, minimum and maximum. Scores of

qualityoflifewerecomparedbetweengendersandbetween

thosewhohadorhadnotusedantiretroviraldrugsinthelast

monthbytheMann–Whitneynonparametrictest.

Furthermore,the depressionand anxiety variableswere

categorized in dichotomous variables (minimal and mild,

and moderate and severe), with moderate and severe

being considered as the presence of clinically significant

symptomatology.19,22 _{Comparisons among dimensions of}

qualityoflifewerecarriedoutusingtheMann–Whitney

non-parametrictest.Inthesameway,Pearson’schi-squaredtest

was usedtoevaluatewhetherthe intensity ofanxiety and

gender,andalsowhetherthemostrelevantreasonreported

bytheparticipantsforstoppingHAARTwasassociatedwith

the intensityof depressionsymptoms. Ap-value less than

0.05 was considered statisticallysignificant. TheStatistical

PackagefortheSocialSciences(SPSS)version20.0for

Win-dowswasused.

Ethicalconsiderations

ThepresentstudywasapprovedbytheResearchEthics

Com-mitteeoftheSchoolofMedicineoftheFederalUniversityof

Bahia,inAugustof2015(casenumber1.154.393).All

partici-pantssignedawrittenconsentform.

Results

Thesociodemographiccharacteristicsoftheparticipantsare

presentedinTable1.Ofthe47participants,70.2%werefemale,

meanage41.9years(±10.5),and46.8%self-reportedasbeing

ofblackethnicity.Regardingmaritalstatus,46.8%were

sin-gleand40.4%married;themajority(89.4%)washeterosexual.

Only 53.2% had an individual income, and of these 23.4%

reported the income originated from disability/retirement

insurancepaymentrelatedtoillness.Intherealmofsocial

support,91.6%oftheparticipantsreportedthatthefamilywas

awareoftheHIVdiagnosis,and83%reportedhavingfamily

support.Alcoholconsumptioninthelastthreemonthswere

admittedby51.1%,with21.3%havingconsumedatleastonce

aweek,and14.9%hadheavyalcoholconsumption,defined

asfiveormoredosesmorethanonceaweek.Only6.4%(all

males)reporteduseofotherpsychoactivesubstancesin

addi-tiontoheavyalcoholconsumption.

The clinical and psychological characteristics are listed

inTable2. Themeannumber ofyearssincediagnosiswas

13.5(minimum2andmaximum28),andtheaverage

num-berofyearsontreatmentwas13(minimum1andmaximum

20);atthetimeofevaluationthemeanTCD4+lymphocytes

was366cells/␮L(minimum1and maximum970),and 80%

oftheparticipantspresenteda viralload between400and

100,000copies. Moreover,among the participantswho had

otherchronicdiseasesrequiringmedication,depressionwas

themostcommon,with31.2%.Itisrelevantbecause59.5%

ofall patients presentedmoderate to severe symptoms of

depression, and 44.7% presented anxiety symptoms. That

meansthatonlyaminoritywereontreatmentforsuch

prob-lems.AnassociationwasalsofoundbetweenstoppingHAART

duetofeelingdepressedandmoderateandsevereintensityof

depressionsymptoms(p=0.02).Whenevaluatingthe

associa-tionofgenderwithanxietyanddepression,anassociationwas

observedbetweenthefemalesexandmoderateandsevere

anxiety symptoms (p=0.006) but there was no association

betweengenderandsymptomsofdepression(p=0.13).

Regardingadherence,although51.1%ofthe participants

presented adherence equal to or greater than 95% in the

previousfourdays,57.4%didnottakesomeofthemedication

in the previous week, and 74.5% in the month prior. The

mostrelevantreasonfornottakingHAART(Fig.2)wasbeing

depressed,with46.8%,andother reasons were beingaway

from home 44.7%; forgetfulness; avoiding undesired side

Table1–Sociodemographiccharacteristicsofthe participantswithHIV/AIDSwhopresentpooradherence toHAART,inSalvador,Bahia,2016.

Variables Totaln=47(%)

Femalesex 33(70.2)

Age(years)(mean,Ds) 41.9(±10.5)

Ethnicity Black 22(46.8) Raciallymixed 13(27.7) White 10(21.3) Indigenous 2(4.3) Education

Elementaryschool,complete/incomplete 22(46.8)

Highschool,complete/incomplete 25(53.2)

Maritalstatus

Single 22(46.8)

Married/livingwithpartner 19(40.4)

Divorced/widowed 6(12.7) Sexualorientation Heterosexual 42(89.4) Homosexual 4(8.5) Bisexual 1(2.1) Individualincome

Hasindividualincome 25(53.2)

Hasnoindividualincome 22(46.8)

Earlyretirementduetoillness 11(23.4)

Familysupport

Support 39(83)

Reject 4(8.6)

Nooneknowsthediagnosis 4(8.6)

Typeofsupporta Spiritual 23(48.9) Emotional 7(14.8) Therapeutic 5(10.6) Financial 12(25.5) Notypeofsupport 8(17) Alcohol

Consumedalcoholinthelastthreemonths 24(51.1) Frequentalcoholconsumption(atleast

onceaweek)

10(21.3) Heavyalcoholconsumption 7(14.9)

Psychoactivesubstanceconsumption 3(6.4)

Misseddoctor’sappointmentinthelast6months 25(53.2) a _{Includingfamilysupport.}

effects,andtakingthepillsatspecifictimes,with38.3%each.

On the other hand,even though 89.4% ofthe participants

acknowledgedthattakingHAARThelpsoneremainhealthy

for a longer time, they alsoshowed somenegative beliefs

relatedtothetreatment:89.4%believedthatthesideeffects

wereintense,74.4%thoughtthattakingHAARTmeantyouhad

AIDS,and72.3%hadthebeliefthatHAARTwastoxic(Table3).

When evaluatingquality ofliferelatedtohealth froma

multidimensionalapproach,itwasobservedthatthe

partic-ipants presentedlower than expected(by scale’s reference

values) mean scores in all the dimensions (Table 4), with

thedimensionsofthementalcomponenthavingthelowest

score.Moreover,whencomparinggender,womenhadlower

44,7% 29.8% 38.3% 17.0% 38.3% 29.8% 25.5% 17.0% 29.8% 31.9% 46.8% 38.3% 14.9% 17.0% 0% 10% 20% 30% 40% 50%

Being out of the house Being busy with other things Forgetting Number of pills to take Avoiding undesirable side effects Not being observed taking the meds Change in daily routine Feel the drug is toxic/harmful Sleeping when time to take dose Feel sick or indisposed Feel depressed Specific hours to take meds No more pills Feel well

Fig.2–ReasonsforstoppingtherapyamongHIV/AIDSpatientswhopresentpooradherencetoHAART,inSalvador,Brazil.

p=0.03),mentalhealth(males:40.2,females:32.3;p=0.008)

andmentalcomponentsummary(males:39.5,females:31.7;

p=0.014). Furthermore, the patients who missed doses of

antiretrovirals in the previous month had lower scores in

thedimensionsofgeneralhealth(yes39.2,not50.9;p=0.01)

andbodilypain(yes41.8,not50.8;p=0.01).Whencomparing

intensityofanxietyanddepressionsymptoms(Table4),the

Table2–Clinicalandpsychologicalcharacteristicsof participantswithHIV/AIDSwhopresentpooradherence toHAART,treatedinSalvador,Bahia,2016.

Variables Totaln=47(%)

Yearssincediagnosis(n=45)(Md;min-max) 13.5(2–28)

YearsofHAART(n=40)(Md;min-max) 13(1–20)

Numberofpillsperday(Md;min-max) 3(1–9)

Self-reportedAdherence≥95% 24(51.1)

CD4+(Md;min-max) 366(1–970)

Viralload(n=45)

400–100,000 36(80)

100,000 9(20)

Otherchronicdiseaseswithmedication 16(34.0)

Depressionwithmedication 5(10.6)

Depressiona Minimal 9(19.1) Mild 10(21.3) Moderate 19(40.4) Severe 9(19.1) Anxietyb Minimal 11(23.4) Mild 15(31.9) Moderate 13(27.7) Severe 8(17.0)

a _{BeckDepressionInventory–BDI,Portugueseversion.Minimal} 0–11,Mild12–19,Moderate20–35andSevere36–63.

b _{BeckAnxietyInventory–BAI,Portugueseversion.Minimal0–10,} Mild11–19,Moderate20–30andSevere31–63.

patientswhohadmoderateandseveresymptomsof

depres-sionoranxietyalsohadlowerscoresinalldimensionsexcept

depressionwithbodilypain(p=0.12)andanxietywith

physi-calfunctioning(p=0.63),generalhealth(p=0.35)andphysical

componentsummary(p=0.42).

Discussion

Theaimofthisstudywastoidentifytherelevant

character-isticsthatmighthavebeenassociatedwithnon-adherenceto

treatment,inagroupofpatientswhopresentedpoor

adher-encetoHAART.Duringthetimeperiodofthestudy,898(64.4%)

menand497(35.6%)womenweretreatedattheHUPES

out-patientclinic.Itisnoteworthythatmorewomen(33subjects,

70%ofsample)showedpooradherencetoHAART.Thisresult

isconsistentwithastudydevelopedinBeloHorizonte,MG,

thatconfirmedpooreradherenceamongwomen.23_Likewise,

anothermulticentricstudydevelopedbytheAIDSClinical

Tri-alsGroupintheUnitedStates,PuertoRicoandItaly24_reported

women as havinga greater risk ofvirologic failure due to

pooradherence.Nevertheless,thereareotherrecentstudies

Table3–BeliefsaboutHAARTofparticipantswith HIV/AIDS,treatedinSalvador,Bahia,2016,whopresent pooradherencetoantiretroviraltherapy.

Variables Totaln=47(%)

UndergoingHAARTisagoodidea evenifyoudon’thavesymptoms

37(78.7)

HAARThasdemonstrateditsefficacy 32(68.0)

ByundergoingHAARTapersonwillbe healthyforlonger

42(89.4) Sideeffectsareintenseformost

people

42(89.4) UndergoingHAARTmeansyouhave

AIDS

35(74.4)

Table4–Qualityoflifescores,comparedbylevelsofdepressionandanxietyofparticipantswithHIV/AIDS,treatedin Salvador,Bahia,2016,whopresentpooradherencetoHAART.

Dimensions Totaln=43Mean

(SD)a

Median Depression,median Anxiety,median

Minimal andmild Moderate andsevere p-Value Minimal andmild Moderate andsevere p-Value Physicalfunctioning 40.65(10.49) 42.4 44.6 39.1 0.008b _{40.4 44.6 0.63} PhysicalRole 38.47(10.62) 35.0 42.1 27.9 0.002b _{42.1 27.9 0.03}b BodilyPain 41.62(10.73) 42.1 46 37.9 0.12 46 37.9 0.008b GeneralHealth 41.23(11.13) 41.5 46.2 37.5 0.04b _{43.9 39.2 0.35} Vitality 41.29(10.58) 39.6 49 36 0.001c _{45.5 34.8 0.03}b SocialFunctioning 36.05(12.43) 35.4 40.8 30 0.003b _{40.8 24.6 0.008}b EmotionalRole 32.06(12.70) 23.7 34.3 23.7 0.01b _{29 23.7 0.02}b MentalHealth 34.06(13.97) 36.8 39 27.7 0.003b _{39.1 23.2 0.002}b

Physicalcomponentsummary 43.96(9.64) 42.9 49.3 39.8 0.04b _{46.1 41.8 0.42}

Mentalcomponentsummary 33.19(13.35) 32.9 36.1 26.1 0.002b _{36.2 25.8 0.002}b

a _{ReferencescoresnormalizedbyShortForm-36mean50SD10.} b _{p<0.05forMann–WhitneyUtest.}

c _{p<0.01forMann–WhitneyUtest.}

thatdidnotfindarelationshipbetweengenderandlevelsof

adherence.25,26 _{Moreover,asystematicreviewondifferences}

ofadherenceaccordingtogenderfoundamarginally

signifi-cantdifferenceofloweradherenceinwomen.27

Thisstudyalsoinvestigatedtheparticipants’beliefsabout

HAARTandthereasonsfornotusingthetreatment.Although

they admitted that HAART was effective and helped one

toremainhealthy foralonger time,negativeideasrelated

to side effects, toxicity, and the concept that undergoing

HAARTmeantonehadAIDSwerealsopresented.Areview

article on adherence and HAART demonstrated that the

patient’s belief system about the nature of the illness, its

treatment,andthefearsregardingsideeffectsmaybe

impor-tantobstaclestoadherence.6_{Itisnoteworthythatavoiding}

undesirablesideeffectswasalsooneoftherelevantreasons

reported by38.3% ofthe participants for stopping HAART,

afinding thatisnearthe 33.3%foundinanother Brazilian

study.28

Highprevalenceofdepressionandsymptomsof

depres-sion have been widely demonstrated in the literature in

patientswithHIV/AIDS.Prevalencestudiesreporteda28.1%in

France,29_{25.6%intheUnitedStates,}30_{and32%inBrazil.}31

Sev-eralstudiesmentiondepressionasoneofthemostimportant

barrierstoadheringtoHAART.6,32_{Inthisstudy,wefoundthat}

thereasonforstoppingHAARTbecauseoffeelingdepressed

wasassociatedwithmoderate and severelevels of

depres-sion symptoms. This finding is even more relevant when

consideringthatfeeling depressedwas the greatestreason

reportedbytheparticipantsforstoppingHAARTandthatmost

(59.5%)ofthempresentedclinicallysignificantsymptomsof

depression.19,22

Thepercentageofparticipantswhopresenteddepressive

symptomsbetweenmoderateandsevere(59.5%)was

signif-icantlyhigherthanthose fromotherBrazilianstudies(18%

and21.5%),31,33_{thatevaluatedpatientswithHIVwhodidnot}

necessarilyhaveadherenceissues asinthispresent study.

Inaddition, only 10.6%had prescriptions ofantidepressive

drugs.Otherstudiesmentionthatbetween50%and60%of

thepatientswithdepressionareundiagnosed.31

Therates ofmoderate and severe symptomsofanxiety

were higher inthis study (44.7%)than inanother previous

studyinBrazil(35.8%),thatdetectedsymptomsofsevere

anx-iety(12.6%)asanimportantpredictorfornon-adherenceto

HAART.33 _{Since our work was focused on a non-adherent}

population, our results were expected, and reinforces the

importanceofanxietyintheadherenceprocess.A

relation-ship with the intensity of anxiety symptoms and female

genderwasalsoobserved,whichisconsistentwithastudy

publishedin2016.34 _{Thisalsoreinforcestheimportanceof}

findingahighproportionofwomeninourstudy.

Differencesbygenderwerealsoobservedinsome

dimen-sions of quality of life: women had lower scores in the

dimensionsvitality, mentalhealth, and mentalcomponent

summary,whichmightberelatedtothefactthattheyhad

moresymptomsofmoderateandsevereanxietythandidmen.

In apreviouslypublished Brazilianwork it was foundthat

womenlivingwithHIVandpatientswithanxietyhadworse

qualityoflifescores.35

OneofthepurposesofHAARTistoimprovethequalityof

lifeofpatients,whichisconfirmedbyseveralstudiesthathave

shownanimprovementinqualityoflifeafterpatientsstarted

therapy.36,37Inthisstudy,however,itwasdemonstratedthat

thequalityoflifeofpatientswhoshowedpooradherencewas

lowerinallthedimensions,andmentalhealthwasthemost

affected.Furthermore,whencomparedtoanotherstudy

con-ducted inBrazilin2009,withHIV/AIDSpatients,regardless

oftheadherencelevel,theseresultsretainlowerscoresinall

components,includingmentalcomponentsummary.38_Onthe

otherhand,amulticentricstudythatevaluatedthechanges

duringoneyearinqualityoflifeofpatientsonHAART

con-cludedthatpatientswithlessthan80%adherencetoHAART

hadlowerqualityoflife,andpatientswithcontinuous

adher-encetoHAARThadimprovementsinqualityoflife,36_which

couldexplaininparttheresultsofthepresentstudy.

Similarly, several studies established the association of

lowerqualityoflifewithdepressionandanxiety,39,40_someof

whichweredevelopedinBrazil.37,41 _{Inthisstudy,presenting}

wasassociatedwithlowerscoresinsomedimensionsof

phys-icalhealthandmentalhealth.

Inaddition,ourstudyshowedasignificantlyhigher

pro-portionofwomenamongnon-adherentpatients,andastrong

associationbetweenthepresenceofmoderateorseverelevels

ofanxiety,depressionsymptoms,andlowscoresinqualityof

life.Similarcharacteristicswerefoundinastudypublishedin

2016,carriedoutinThailandinpatientswithHIV/AIDS,which

foundassociationsbetweenanxietyinfemalepatientswith

pooradherencetoHAARTandassociationsbetweenanxiety

anddepressionwithlowqualityoflife.34_{Therefore,thereis}

aneedforfurtherstudiestoclarifyandunderstandhow

gen-der,anxiety,depression,andqualityoflifemightbeassociated

withadherencetoHAART.

Theroleofthepsychologicalcomponentisconsideredto

befundamental inthe management of HIV/AIDS patients.

Psychoeducationshould beused toreducenegativebeliefs

regardingantiretroviraltherapy,beyondtheinitialevaluation

andsubsequentassessmentsofanxietyanddepression

symp-toms.Thesepointswarrantgreaterattentionbecausetheyare

associatedwithadherence,thesuccessofthetreatmentand

ultimately,withthepatients’qualityoflife.Furthermore,itis

pertinenttodevelopstudiesrelatedtowomen’sadherenceto

HAART,togatherthenecessaryinformationthatwouldallow

theimplementationofdifferentiatedinterventionstailoredto

women.

Finally,thelimitationsofthiscross-sectionalstudyinclude

difficultiesinestablishingcausalrelationshipstopoor

adher-ence,theuse ofself-report toassess adherence thatcould

foster under- or overestimating the rates of participants’

adherence,andthesmallsamplesize.However,self-reported

adherenceisavalidatedmethodtoevaluatetheproperuseof

antiretroviraldrugs,despitesomeclearlimitations.16_Theuse

ofabiologicalmarker(viralload)reducestheeffectof

inac-curateself-reportedadherencelevels.Inaddition,ourresults

clearlypointedouttotheimportanceofabetterevaluationof

psychologicalaspectsofwomenfailingantiretroviraltherapy

duetonon-adherence.Strategiestoovercomethesebarriers

areurgentlyneeded.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1. BRASIL.CongressoNacional.Lein◦9.313,13denovembrode

1996.Dispõesobreadistribuic¸ãogratuitademedicamentos

aosportadoresdoHIVedoentesdeAIDS.DiárioOficial[da

RepúblicaFederativadoBrasil],Brasília,DF.(14denov1996).

2. MinisteriodaSaúde.SecretariadeVigilânciaemSaúde. Protocoloclínicoediretrizesterapêuticasparamanejoda infecc¸ãopeloHIVemadultos.Brasilia:DepartamentodeDTS, AidseHepatitesVirais;2013.p.216.

3. GünthardHF,SaagMS,BensonCA,etal.Antiretroviraldrugs fortreatmentandpreventionofHIVinfectioninadults:2016 recommendationsoftheinternationalantiviralsociety–USA panel.JAMA.2016;316:191–210.

4.BangsbergDR,PerryS,CharleboisED,etal.Non-adherenceto highlyactiveantiretroviraltherapypredictsprogressionto AIDS.AIDS.2001;15:1181–3.

5.ThompsonMA,AbergJA,HoyJF,etal.Antiretroviral treatmentofadultHIVinfection:2012recommendationsof theinternationalantiviralsociety–USApanel.JAMA. 2012;308:387–402.

6.ChesneyM.AdherencetoHAARTregimens.AIDSPatientCare STDS.2003;17:169–77.

7.PeltzerK,RamlaganS,JonesD,WeissSM,FomundamH, ChanetsaL.Efficacyofalayhealthworkerledgroup antiretroviralmedicationadherencetrainingamong non-adherentHIV-positivepatientsinKwaZulu-Natal,South Africa:resultsfromarandomizedtrial.SAHARAJ.

2012;9:218–26.

8.deCarvalhoCV,Merchan-HamannE,MatsushitaR. [Determinantsofantiretroviraltreatmentadherencein Brasilia,FederalDistrict:acase-controlstudy].RevSocBras MedTrop.2007;40:555–65.

9.BonoloPF,MachadoCJ,CesarCC,CeccatoM,GuimarãesMD. Vulnerabilityandnon-adherencetoantiretroviraltherapy amongHIVpatients,MinasGeraisState,Brazil.CadSaude Publica.2008;24:2603–13.

10.BrigidoLF,RodriguesR,CassebJ,etal.Impactofadherenceto antiretroviraltherapyinHIV-1-infectedpatientsata

universitypublicserviceinBrazil.AIDSPatientCareSTDS. 2001;15:587–93.

11.RemienRH,BastosFI,JnrVT,etal.Adherenceto

antiretroviraltherapyinacontextofuniversalaccess,inRio deJaneiro,Brazil.AIDSCare.2007;19:740–8.

12.IckovicsJR,MeadeCS.AdherencetoHAARTamongpatients withHIV:breakthroughsandbarriers.AIDSCare.

2002;14:309–18.

13.FogartyL,RoterD,LarsonS,BurkeJ,GillespieJ,LevyR.Patient adherencetoHIVmedicationregimens:areviewofpublished andabstractreports.PatientEducCouns.2002;46:

93–108.

14.SilvaJA,DouradoI,BritoAM,SilvaCA.Factorsassociated withnon-adherencetoantiretroviraltherapyinadultswith AIDSinthefirstsixmonthsoftreatmentinSalvador,Bahia State,Brazil.CadSaudePublica.2015;31:1188–98.

15.ZubaranC,MedeirosG,ForestiK,MayW,MichelimL,Madi JM.Qualityoflifeandadherencetoantiretroviraltherapyin SouthernBrazil.AIDSCare.2014;26:619–25.

16.ACTG,Adherencefollowupquestionnaire.Availablefrom:

https://www.frontierscience.org/apps/cfmx/apps/common/ QOLAdherenceForms/resources/actg/forms/english/ql0702

.pdf[accessed5.5.16].

17.RicciG,NettoEM,LuzE,RodamilansC,BritesC.Adherenceto antiretroviraltherapyofBrazilianHIV-infectedchildrenand theircaregivers.BrazJInfectDis.2016;20:429–36.

18.Sampaio-SaM,Page-ShaferK,BangsbergDR,etal.100% adherencestudy:educationalworkshopsvs.videosessionsto improveadherenceamongART-naivepatientsinSalvador, Brazil.AIDSBehav.2008;124Suppl:S54–62.

19.Gomes-OliveiraMH,GorensteinC,LotufoNetoF,AndradeLH, WangYP.ValidationoftheBrazilianPortugueseversionofthe BeckDepressionInventory-IIinacommunitysample.Rev BrasPsiquiatr.2012;34:389–94.

20.CunhaJA.ManualdaversãoemportuguêsdasEscalasBeck. SãoPaulo:CasadoPsicólogo;2001.

21.CiconelliRM,FerrazMB,SantosW,MeinãoI,QuaresmaMR. Traduc¸ãoparaalínguaportuguesaevalidac¸ãodo

questionáriogenéricodeavaliac¸ãodequalidadedevida SF-36(BrasilSF-36).RevBrasReumatol.1999;39:143–50.

22.DozoisDJA,DobsonKS,AhnbergJL.Apsychometric evaluationoftheBeckDepressionInventory-II.Psychol Assess.1998;10:83–9.

23.BonoloPF,CesarCC,AcurcioFA,etal.Non-adherenceamong patientsinitiatingantiretroviraltherapy:achallengefor healthprofessionalsinBrazil.AIDS.2005;19Suppl4:S5–13.

24.CollierAC,RibaudoH,MukherjeeAL,FeinbergJ,FischlMA, ChesneyM.Arandomizedstudyofserialtelephonecall supporttoincreaseadherenceandtherebyimprovevirologic outcomeinpersonsinitiatingantiretroviraltherapy.JInfect Dis.2005;192:1398–406.

25.McCoyK,Waldrop-ValverdeD,BaldersonBH,MahoneyC, CatzS.Correlatesofantiretroviraltherapyadherenceamong HIV-infectedolderadults.JIntAssocProvidAIDSCare. 2016;15:248–55.

26.BeerL,MattsonCL,BradleyH,SkarbinskiJ.Understanding cross-sectionalracial,ethnic,andgenderdisparitiesin antiretroviraluseandviralsuppressionamongHIVpatients intheUnitedStates.Medicine(Baltimore).2016;95:e3171.

27.OrtegoC,Huedo-MedinaTB,SantosP,etal.Sexdifferencesin adherencetohighlyactiveantiretroviraltherapy:a

meta-analysis.AIDSCare.2012;24:1519–34.

28.GuimarãesMD,RochaGM,CamposLN,etal.Difficulties reportedbyHIV-infectedpatientsusingantiretroviraltherapy inBrazil.Clinics(SaoPaulo).2008;63:165–72.

29.FeuilletP,LertF,TronL,AubriereC,SpireB,Dray-SpiraR. Prevalenceofandfactorsassociatedwithdepressionamong peoplelivingwithHIVinFrance.HIVMed.2016.

30.DoAN,RosenbergES,SullivanPS,etal.Excessburdenof depressionamongHIV-infectedpersonsreceivingmedical careintheUnitedStates:datafromthemedicalmonitoring projectandthebehavioralriskfactorsurveillancesystem. PLoSOne.2014;9:e92842.

31.SilveiraMP,GuttierMC,PinheiroCA,PereiraTV,CruzeiroAL, MoreiraLB.DepressivesymptomsinHIV-infectedpatients treatedwithhighlyactiveantiretroviraltherapy.RevBras Psiquiatr.2012;34:162–7.

32.KrummeAA,KaigambaF,BinagwahoA,MurrayMB,RichML, FrankeMF.Depression,adherenceandattritionfromcarein

HIV-infectedadultsreceivingantiretroviraltherapy.J EpidemiolCommunHealth.2015;69:284–9.

33.CamposLN,GuimarãesMD,RemienRH.Anxietyand depressionsymptomsasriskfactorsfornon-adherenceto antiretroviraltherapyinBrazil.AIDSBehav.2010;14: 289–99.

34.PrasithsirikulW,ChongthawonsatidS,OhataPJ,etal. Depressionandanxietywerelowamongstvirallysuppressed, long-termtreatedHIV-infectedindividualsenrolledina publicsectorantiretroviralprograminThailand.AIDSCare. 2016:1–7.

35.PassosSM,SouzaLD.Anevaluationofqualityoflifeandits determinantsamongpeoplelivingwithHIV/AIDSfrom SouthernBrazil.CadSaudePublica.2015;31:800–14.

36.MannheimerSB,MattsJ,TelzakE,etal.Qualityoflifein HIV-infectedindividualsreceivingantiretroviraltherapyis relatedtoadherence.AIDSCare.2005;17:10–22.

37.CamposLN,CesarCC,GuimarãesMD.Qualityoflifeamong HIV-infectedpatientsinBrazilafterinitiationoftreatment. Clinics(SaoPaulo).2009;64:867–75.

38.SoarezPC,CasteloA,AbrãoP,HolmesWC,CiconelliRM. [Brazilian-Portuguesetranslationandvalidationofthe HIV/AIDS-TargetedQualityofLifeInstrument].RevPanam SaludPublica.2009;25:69–76.

39.EzeamamaAE,WoolforkMN,GuwatuddeD,etal.Depressive andanxietysymptomspredictsustainedqualityoflife deficitsinHIV-positiveUgandanadultsdespiteantiretroviral therapy:aprospectivecohortstudy.Medicine(Baltimore). 2016;95:e2525.

40.PeterE,KamathR,AndrewsT,HegdeBM.Psychosocial determinantsofhealth-relatedqualityoflifeofpeopleliving withHIV/AIDSonantiretroviraltherapyatUdupiDistrict, SouthernIndia.IntJPrevMed.2014;5:203–9.

41.TostesMA,ChalubM,BotegaNJ.Thequalityoflifeof HIV-infectedwomenisassociatedwithpsychiatricmorbidity. AIDSCare.2004;16:177–86.