Usefulness of pharmacy dispensing records in the evaluation of adherence to antiretroviral therapy in Brazilian children and adolescents

The Characteristics of Youth With Missed HIV Visits in Alabama

Gaps in knowledge remain related to understanding missed human immunodeficiency virus (HIV) visits and youth with HIV (YWH). This study examined data from an Alabama academic HIV clinic with clients aged 16 to 24 years old and found that non virally suppressed and older YWH were associated with missed visits among YWH.

Caregivers' psychosocial assessment for identifying HIV-infected infants at risk of poor treatment adherence: an exploratory study in southern Mozambique

Psychosocial support (PSS) to caregivers of HIV-infected infants on antiretroviral treatment (ART) is crucial to ensure ART adherence and sustained long-term viral suppression in children. A specific approach including tools to monitor and understand adherence behavior and risk factors that prevent optimal treatment compliance are urgently needed. This qualitative exploratory study, conducted in southern Mozambique, monitored the infants' viral response trajectories during 18 months follow-up, as a measure of adherence, reviewed the caregiver's PSS session notes and the answers to a study questionnaire, to analyze whether the standard PSS checklist applied to infants' caregivers can identify barriers influencing their adherence. Only 9 of 31 infants had sustained virologic response. Reported factors affecting adherence were: difficulties in drugs administration, shared responsibility to administer treatment; disclosure of child's HIV status to family members but lack of engagement; mother's ART interruption and poor viral response. In conclusion, we found that the standard PSS approach alone, applied to caregivers, was lacking focus on many relevant matters that were identified by the study questionnaire. A comprehensive patient-centered PSS package of care, including an adherence risk factor monitoring tool, tailored to caregivers and their children must be developed.

Rubella antibodies in vertically and horizontally HIV-infected young adults vaccinated early in life and response to a booster dose in those with seronegative results

BACKGROUND

Very limited data are available on the persistence of rubella antibodies in vertically HIV-infected individuals who were vaccinated early in life.

METHODS

Prospective, cohort study on 4 groups of patients: 96 vertically HIV-1-infected individuals (v-HIV), 69 horizontally HIV-1-infected individuals (h-HIV), 93 healthy controls previously vaccinated for rubella (vac-CON) and 20 healthy controls with history of rubella disease (dis-CON). A blood sample was collected and rubella antibodies were analyzed by ELISA. Rubella antibodies above 10 IU/mL were considered protective. Individuals with seronegative results were offered an extra MMR vaccine dose and were tested at least 30 days afterwards.

RESULTS

Time since previous rubella vaccination was similar in v-HIV, h-HIV and vac-CON (16, 11 and 11 years; p = 0.428). v-HIV and h-HIV were also comparable regarding median CD4 T cells (613 and 614 cells/mm³; p = 0.599) and percentage on ART (93.8% and 98.6%; p = 0.135) at study entry. v-HIV had less individuals on virological suppression (63.5%) compared to 85.5% in h-HIV (p < 0.001). Rubella seropositivity and antibodies were significantly lower in v-HIV compared to h-HIV (32.3% vs 65.5%, 4.3 IU/mL vs 21.1 IU/mL; p < 0.001). Time interval between the last rubella vaccine dose and study entry was associated with an increase of rubella seronegativity, with a 7% higher chance of seronegativity for each one-year increase. After an extra MMR dose, 40 out of 48 (83.3%) seronegative individuals responded, with no significant difference among groups considering rubella seropositivity and antibody levels.

CONCLUSION

As vertically HIV-infected individuals reach adolescence and adulthood, assessment of vaccine antibodies can identify those who might benefit from an extra vaccine dose.

Unsatisfactory long-term virological suppression in human immunodeficiency virus-infected children in the Amazonas State, Brazil

INTRODUCTION:

Achieving viral suppression (VS) in children is challenging despite the exponential increase in access to antiretroviral therapy (ART). We evaluated VS in children >1 year of age and adolescents 5 years after they had begun ART, in Manaus, Amazonas state, Brazil.

METHODS:

HIV-infected, ART-naive children >1 year of age between 1999 and 2016 were eligible. Analysis was stratified by age at ART initiation: 1-5 y, >5-10 y, and >10-19 y. CD4⁺ T-cell count and viral load were assessed on arrival at the clinic, on ART initiation, and at 6 months, 1 year, 2 years, and 5 years after ART initiation. The primary outcome was a viral load <50 copies/mL 5 years after ART initiation.

RESULTS:

Ultimately, 121 patients were included. The mean age at diagnosis was 4.8 years (SD 3.5), mean CD4% was 17.9 (SD 9.8), and mean viral load was 4.6 log10 copies/ml (SD 0.8). Five years after ART initiation, the overall VS rate was 46.9%. VS by patient age group was as follows: 36.6% for 1-5 y, 53.3% for >5-10 y, and 30% for >10-19 y. Almost all children (90,4%) showed an increase in CD4%+ T cell count. There were no statistically significant predictors for detecting children who do not achieve VS with treatment. VS remained below 65% in all the evaluated periods.

CONCLUSIONS:

Considerable immunological improvement is seen in children after ART initiation. Further efforts are needed to maintain adequate long-term VS levels and improve the survival of this vulnerable population.

The Role of Pharmacy Refill Measures in Assessing Adherence and Predicting HIV Disease Markers in Youth with Perinatally-Acquired HIV (PHIV)

Antiretroviral (ARV) adherence is critical in monitoring disease response in youth with perinatally-acquired HIV (PHIV). We used pharmacy refill (PR) information for PHIV youth from the PHACS Memory Sub-study to calculate medication availability over 2, 4, and 6 months. PR, a proxy of adherence, was compared with self-reported 7-day adherence in predicting suppressed viral load (SVL < 400 copies/mL) and higher CD4% (≥ 25%). Among 159 PHIV youth, 79% were adherent by 7-day recall, and 62, 55, and 48% by PR over 2, 4, and 6 months, respectively. Agreement between 7-day recall and PR adherence was weak (Kappa = 0.09-0.25). In adjusted logistic regression models, adherence showed associations with SVL for 7-day recall (OR 2.78, 95% CI 1.08, 7.15) and all PR coverage periods (6-month: OR 3.24, 95% CI 1.22, 8.65). Similar associations were observed with higher CD4%. PR measures were predictive of study retention. Findings suggest a possibly independent role of PR adherence measures.

Development of a Social Network-Based Intervention to Overcome Multilevel Barriers to ART Adherence Among Adolescents in Brazil

Brazil's comprehensive HIV treatment program does not specifically address ART adherence challenges for adolescents-a group accounting for the largest number of incident HIV infections in Brazil. We conducted three focus groups with 24 adolescents (age 15-24) living with HIV in Rio de Janeiro, separately for cisgender men who have sex with men, heterosexual-identified cisgender men and women, and transgender women of any sexual orientation, and key informant interviews (n = 7) with infectious disease specialists and HIV/AIDS service organization staff. Content analysis identified socioecological barriers and facilitators to adherence, including individual (e.g., low knowledge, side effects, and substance use), interpersonal (e.g., stigma from partners and health care providers) and structural (e.g., transportation and medication access) barriers. Overlapping and unique barriers emerged by sexual/gender identity. A community-informed, theory-driven ART adherence intervention for adolescents that is organized around identity and leverages social networks has the potential to improve HIV treatment and health outcomes for Brazilian adolescents.

[Aspects related to the use of antiretrovirals in high complexity patients in the state of Rio de Janeiro]

Treatment of AIDS involves the use of the cocktail of drugs that make up the antiretroviral therapy. Its logistic control is monitored by a computerized national system of dispensation, the Logistic Control System of Medication (SICLOM). This study aimed to investigate, by means of SICLOM data, the use of antiretroviral therapy in patients treated at two University Hospitals in the state of Rio de Janeiro. A cross-sectional study was conducted with sociodemographic and dispensation data collected from SICLOM. The evaluation of drug ownership was done by calculating the Proportion of Days Covered (PDC). Five hundred and thirty-eight patients of both genders with active registration in SICLOM and over 18 years of age were included. The ART most used in both hospitals was lamivudine, considering the total of 58 different schemes identified. The mean of possession of groups was 88% (± 0,16). The factor associated with possession of drugs was the ART scheme, with PDC of 91% (p<0,001) for rescue schemes. This study confirmed that SICLOM was a reliable source to establish the profile of the population assisted.

High prevalence of non-adherence to antiretroviral therapy among undisclosed HIV-infected children in Ghana

Adherence to antiretroviral therapy (ART) remains one of the greatest obstacles in pediatric HIV care. We sought to determine the prevalence of adherence to ART among undisclosed HIV-infected children and adolescents in Ghana. We analyzed baseline data from HIV-infected children and adolescents aged 7-18 years old enrolled in the SANKOFA Pediatric HIV disclosure intervention study in Ghana. Antiretroviral medication adherence was measured using caregiver 3-day recall; child 3-day recall; and pharmacy records for antiretroviral time-to-refill. Four hundred and twenty child-caregiver dyads were enrolled from January 2013 to June 2016. The median adherence (interquartile range), as measured by time-to-refill, was 93.2% (68.0%-100.0%). However, only 47.5% of children had ≥95% adherence ("good adherence") using time-to-refill data. Children of caregivers who had received secondary or higher level of education versus no school (aOR, 2.90, 95% Confidence Interval, CI 1.29-6.56), p = 0.010) or elementary education only (aOR, 2.20, CI, 1.24-3.88, p = 0.007) were more likely to have "good adherence" (≥95%). In this cohort of children unaware of their HIV positive status, median ART adherence rate was sub-optimal (by World Health Organization definition) while 38% had poor adherence (<85%).

Correlates of missed clinic visits among youth living with HIV

Youth living with HIV (YLH) have significant problems with attending their medical appointments. Poor attendance, consequently, predicts viral non-suppression and other negative health outcomes. To identity targets of intervention, this cross-sectional study examined correlates of past-year missed clinic visits among YLH (N = 2125) attending HIV clinics in the United States and Puerto Rico. Thirty-six percent of YLH missed two or more visits in the past year. Several factors were associated with missed visits in our regression model. Among sociodemographic characteristics and HIV disclosure status, females (adjusted odds ratio [OR] = 1.63, compared to males), Black YLH or YLH of mixed racial heritage (AORs = 1.76, 1.71, respectively, compared to White YLH), YLH with an unknown route of infection (AOR = 1.86, compared to YLH with perinatal infection), and YLH endorsing HIV disclosure (AOR = 1.37, compared to YLH not endorsing disclosure) were at greater risk for missed visits. Among behavioral health risks, YLH who endorsed marijuana use (AOR = 1.42), frequent other drug use (AOR = 1.60), or a history of incarceration (AOR = 1.27) had greater odds of missed visits than youth not endorsing these risks. Finally, two social-cognitive resources emerged as protective factors: adherence self-efficacy (AOR = .28) and social support (AOR = .88). We discuss how providers working with YLH can improve this population's retention outcomes.

Use of pharmacy records to measure treatment adherence: a critical review of the literature

The current frame of reference on adherence to pharmacotherapy includes a set of behaviors experienced by the user, with observation of the detailed and continuous history of the use of each dose of the medication. Indicators based on pharmacy records have been used to measure adherence. The current review aimed to identify and describe indicators based on pharmacy records and to discuss their adequacy and limitations for measuring adherence. An exploratory literature review was conducted in three databases using the terms "adherence", "pharmacy records/administrative data", and "measure" to compose the descriptors for the selection of 81 articles and the elaboration of a chart with the denomination, sources, methods for calculation, description, and interpretation of the operational and referential meaning of 14 indicators. Given the most recent taxonomy for adherence proposed in the literature, we concluded that the indicators can be useful for identifying patients with medication-seeking behavior-related problems and analysis of persistence. The distance between supply-related events and difficulties in treatment follow-up can influence an analysis based exclusively on the use of these indicators.

Impact of HIV-Status Disclosure on Adherence to Antiretroviral Therapy Among HIV-Infected Children in Resource-Limited Settings: A Systematic Review

Pediatric HIV remains a significant global health dilemma, especially in resource-constrained nations. As access to ART increases around the world, areas of concern in pediatric HIV treatment include age-appropriate disclosure of HIV status to children and development of adherence habits over time. This review was conducted to synthesize quantitative associations reported between disclosure and adherence among children living with HIV in resource-limited settings. An electronic database search of PubMed, MEDLINE and Cochrane returned 1348 results after removal of duplicates, 14 of which were found to meet inclusion criteria. Review of these reports showed conflicting results regarding the impact of disclosure on adherence, with 5 showing no association, 4 showing a negative impact of disclosure on adherence, and 5 showing positive benefits of disclosure for adherence habits. Thus, there was no clear consensus on the effect, if any, that disclosure has on medication adherence. Longitudinal, prospective research needs to be conducted to evaluate further impacts that disclosure may have on adherence habits over time, and interventions must be structured to link the two processes together in order to maximize health benefit to the child or adolescent.

Predictors and Evolution of Antiretroviral Therapy Adherence Among Perinatally HIV-Infected Adolescents in Brazil

PURPOSE

Antiretroviral therapy medication adherence is a complex phenomenon influenced by multiple factors. This study examines its evolution and predictors among perinatally HIV-infected youths in São Paulo, Brazil.

METHODS

During a 1-year longitudinal cohort study, perinatally HIV-infected youths aged 13-21 years taking antiretroviral therapy were recruited in hospitals and HIV/AIDS reference centers. Data were collected at baseline and after 12 months. Variables assessed were adherence, self-efficacy regarding medication intake, social support, stress level, depression, CD4 cell count, viral load, and symptoms. Adherence was defined as taking ≥95% of prescribed HIV medication in the past 7 days. Generalized estimating equation and analysis of variance methods were used.

RESULTS

A total of 268 adolescents participated in the study (59% female; mean age of 16 years). At baseline, 63.06% of the sample was adherent to their HIV medication, and 52.99% had an undetectable viral load. All participants, regardless of adherence, reported: low levels of stress and symptoms of depression; high perception of medication self-efficacy and social support; and a mean of 6.8 symptoms related to their HIV medication. Predictors of adherence were: high perception of medication self-efficacy (odds ratio = 2.81; 95% confidence interval: 1.94-4.05) and low number of reported medication side effects (odds ratio = .97; 95% confidence interval: .95-.99]. Between baseline and follow-up, 49.6% remained adherent, 22.3% remained nonadherent, and the adherence level changed over time for 28.2%.

CONCLUSIONS

These findings suggest the need to develop interventions to enhance self-efficacy toward medication and to help youth better manage HIV medication symptoms.

Adherence to antiretroviral therapy of Brazilian HIV-infected children and their caregivers

BACKGROUND

Successful treatment of HIV-positive children requires a high level of adherence (at least 95%) to highly active antiretroviral therapy. Adherence is influenced by factors related to the child and caregivers.

OBJECTIVES

To evaluate children and caregivers characteristics associated to children's adherence.

METHODS

Cross-sectional study, from September 2013 to June 2015, comprising a sample of caregivers of perinatally HIV-infected children, in the age group of 1-12 years, under antiretroviral therapy for at least 6 months and on follow-up in two AIDS reference centers in Salvador, Bahia. Caregiver self-reports were the sole source of 4 days adherence and sociodemographic information. Study participants who reported an intake >95% of prescribed medication were considered adherents. A variable, ("Composed Adherence"), was created to better evaluate adherence.

RESULTS

We included 77 children and their caregivers. 88.3% of the caregivers were female, the median age was 38.0 years (IQR 33.5-47.5), 48.1% were white or mixed, 72.7% lived in Salvador and 53.2% had no fixed income. The 4 days child's adherence was associated only to caregivers that received less than a minimum salary (p<0.05), 70.1% of the caregivers had less than four years of formal education, 81.8% were children's relative and 53.2% of the caregivers were HIV positive. The caregiver's pharmacy refill, long-term adherence and 4 days adherence, were significantly associated with composed adherence (p<0.05). Child's long-term adherence was strongly associated to the 4 days child's adherence referred by caregiver (p<0.001).

CONCLUSIONS

Our results suggest the need of improvement in HIV-infected children adherence, through reinforcement of the caregivers own adherence.

Factors associated with adherence to antiretroviral therapy among adolescents living with HIV/AIDS in low- and middle-income countries: a systematic review

Adolescents living in low- and middle-income countries (LMICs) are disproportionately burdened by the global HIV/AIDS pandemic. Maintaining medication adherence is vital to ensuring that adolescents living with HIV/AIDS receive the benefits of antiretroviral therapy (ART), although this group faces unique challenges to adherence. Knowledge of the factors influencing adherence among people during this unique developmental period is needed to develop more targeted and effective adherence-promoting strategies. This systematic review summarizes the literature on quantitative observational studies examining correlates, including risk and resilience-promoting factors, of ART adherence among adolescents living with HIV/AIDS in LMICs. A systematic search of major electronic databases, conference-specific databases, gray literature, and reference lists of relevant reviews and documents was conducted in May 2014. Included studies examined relationships between at least one factor and ART adherence as an outcome and were conducted in primarily an adolescent population (age 10-19) in LMICs. The search identified 7948 unique citations from which 15 studies fit the inclusion criteria. These 15 studies identified 35 factors significantly associated with ART adherence representing a total of 4363 participants across nine different LMICs. Relevant studies revealed few consistent relationships between measured factors and adherence while highlighting potentially important themes for ART adherence including the impact of (1) adolescent factors such as gender and knowledge of serostatus, (2) family structure, (3) the burdensome ART regimens, route of administration, and attitudes about medication, and (4) health care and environmental factors, such as rural versus urban location and missed clinic appointments. Rates of adherence across studies ranged from 16% to 99%. This review identifies unique factors significantly related to ART adherence among adolescents living in LMICs. More research using longitudinal designs and rigorous measures of adherence is required in order to identify the range of factors influencing ART adherence as adolescents living with HIV/AIDS in LMICs grow into adulthood.

Viral suppression and adherence among HIV-infected children and adolescents on antiretroviral therapy: results of a multicenter study

OBJECTIVE

To evaluate treatment adherence among perinatally-infected pediatric human immunodeficiency virus (HIV) patients followed in pediatric centers in Brazil.

METHODS

This was a cross-sectional multicenter study. Medical records were reviewed and adherence scale, assessment of caregivers' quality of life (WHOQOL-BREF), anxiety, depression, and alcohol/substances use/abuse were assessed. Outcomes included self-reported 100% adherence in the last three days and HIV viral load (VL)<50 copies/mL. Statistical analyses included contingency tables and respective statistics, and multivariable logistic regression.

RESULTS

260 subjects were enrolled: 78% children and 22% adolescents; 93% of caregivers for the children and 77% of adolescents reported 100% adherence; 57% of children and 49% of adolescents had VL<50 copies/mL. In the univariate analyses, HIV diagnosis for screening due to maternal infection, lower caregiver scores for anxiety, and higher scores in physical and psychological domains of WHOQOL-BREF were associated with 100% adherence. Shorter intervals between pharmacy visits were associated with VL<50 copies/mL (p ≤ 0.01). Multivariable regression demonstrated that caregivers who did not abuse alcohol/other drugs (OR=0.49; 95% CI: 0.27-0.89) and median interval between pharmacy visits<33 days (OR=0.97; 95% CI: 0.95-0.98) were independently associated with VL<50 copies/mL; whereas lower caregiver scores for anxiety (OR=2.57; 95% CI: 1.27-5.19) and children's HIV diagnosis for screening due to maternal infection (OR=2.25; 95% CI: 1.12-4.50) were found to be independently associated with 100% adherence.

CONCLUSIONS

Pediatric HIV programs should perform routine assessment of caregivers' quality of life, and anxiety and depression symptoms. In this setting, pharmacy records are essential to help identify less-than-optimal adherence.

Appointment keeping for medical review among patients with selected chronic diseases in an urban area of Uganda

Introduction

Proper management of chronic diseases is important for prevention of disease complications and yet some patients miss appointments for medical review thereby missing the opportunity for proper monitoring of their disease conditions. There is limited information on missed appointments among chronic disease patients in resource limited settings. This study aimed to determine the prevalence of missed appointments for medical review and associated factors among chronic disease patients in an urban area of Uganda.

Methods

Patients or caregivers of children with chronic diseases were identified as they bought medicines from a community pharmacy. They were visited at home to access their medical documents and those whose chronic disease status was ascertained were enrolled. The data was collected using: questionnaires, review of medical documents, and in-depth interviews with chronic disease patients.

Results

The prevalence of missed appointments was 42% (95%CI = 35-49%). The factors associated with missed appointments were: monthly income ≤30US Dollars (OR = 2.56, CI = 1.25–5.26), affording less than half of prescribed drugs (OR = 3.92, CI = 1.64–9.40), not experiencing adverse events (OR = 2.66, CI = 1.26–5.61), not sure if treatment helps (OR = 2.84, CI = 1.047.77), not having a medicines administration schedule (OR = 6.77, CI = 2.11–21.68), and increasing number of drugs (OR = 0.72, CI = 0.53–0.98).

Conclusion

Patients missed appointments mainly due to: financial and health system barriers, conflicting commitments with appointments, and perceptions of the disease condition. Patients should be supported with accessible and affordable health services.

Scale-up of networked HIV treatment in Nigeria: creation of an integrated electronic medical records system

OBJECTIVES

The implementation of PEPFAR programs in resource-limited settings was accompanied by the need to document patient care on a scale unprecedented in environments where paper-based records were the norm. We describe the development of an electronic medical records system (EMRS) put in place at the beginning of a large HIV/AIDS care and treatment program in Nigeria.

METHODS

Databases were created to record laboratory results, medications prescribed and dispensed, and clinical assessments, using a relational database program. A collection of stand-alone files recorded different elements of patient care, linked together by utilities that aggregated data on national standard indicators and assessed patient care for quality improvement, tracked patients requiring follow-up, generated counts of ART regimens dispensed, and provided 'snapshots' of a patient's response to treatment. A secure server was used to store patient files for backup and transfer.

RESULTS

By February 2012, when the program transitioned to local in-country management by APIN, the EMRS was used in 33 hospitals across the country, with 4,947,433 adult, pediatric and PMTCT records that had been created and continued to be available for use in patient care. Ongoing trainings for data managers, along with an iterative process of implementing changes to the databases and forms based on user feedback, were needed. As the program scaled up and the volume of laboratory tests increased, results were produced in a digital format, wherever possible, that could be automatically transferred to the EMRS. Many larger clinics began to link some or all of the databases to local area networks, making them available to a larger group of staff members, or providing the ability to enter information simultaneously where needed.

CONCLUSIONS

The EMRS improved patient care, enabled efficient reporting to the Government of Nigeria and to U.S. funding agencies, and allowed program managers and staff to conduct quality control audits.

Adherence to antiretroviral therapy in adolescents living with HIV: systematic review and meta-analysis

Objective:

Adolescent and young adult (AYA) populations (12–24 years) represent over 40% of new HIV infections globally. Adolescence is sometimes characterized by high-risk sexual behaviour and a lack of engagement with healthcare services that can affect adherence to antiretroviral therapy (ART). Despite adherence to ART being critical in controlling viral replication, maintaining health and reducing onward viral transmission, there are limited data on ART adherence amongst AYA globally. We undertook a systematic review and meta-analysis of published studies reporting adherence to ART for AYA living with HIV.

Design and methods:

Searches included Embase, Medline and PsychINFO databases up to 14 August 2013. Eligible studies defined adequate adherence as at least 85% on self-report or undetectable blood plasma virus levels. A random effects meta-analysis was performed and heterogeneity examined using meta-regression.

Results:

We identified 50 eligible articles reporting data from 53 countries and 10 725 patients. Using a pooled analysis of all eligible studies, 62.3% [95% confidence interval (CI) 57.1–67.6; I² : 97.2%] of the AYA population were adherent to therapy. The lowest average ART adherence was in North America [53% (95% CI 46–59; I² : 91%)], Europe [62% (95% CI 51–73; I² : 97%)] and South America [63% (95% CI 47–77; I² : 85%] and, with higher levels in Africa [84% (95% CI 79–89; I² : 93%)] and Asia [84% (95% CI 77–91; I² : 0%].

Conclusion:

Review of published literature from Africa and Asia indicate more than 70% of HIV-positive AYA populations receiving ART are adherent to therapy and lower rates of adherence were shown in Europe and North America at 50–60%. The global discrepancy is probably multifactorial reflecting differences between focused and generalised epidemics, access to healthcare and funding.

Investigando a adesão ao atendimento fonoaudiológico no contexto da atenção básica

OBJETIVO: analisar os motivos relacionados a não-adesão de pacientes à terapia fonoaudiológica em um Centro de Saúde de Atenção Básica do Município de Campinas. MÉTODO:estudo exploratório do tipo ex-post facto de caráter qualitativo desenvolvido com os pacientes ou seus responsáveis, atendidos em um serviço de saúde e que não aderiram à fonoterapia. Foram realizadas entrevistas semiestruturadas, com questões semidirigidas, a fim de apreender os motivos e atitudes enunciados pelos pacientes ou seus responsáveis em relação a não-adesão à terapia fonoaudiológica. As entrevistas foram transcritas e sistematizadas considerando-se os pressupostos da Análise Temática, técnica da Análise do Conteúdo. RESULTADOS: foram entrevistados dez sujeitos. Na análise, emergiu uma diversidade de temas e subtemas, desde relativos ao motivo do abandono, até a avaliação dos atendimentos de fonoaudiologia na visão dos usuários e organização da dinâmica familiar para comparecer ao atendimento. Este estudo indicou serem diversos os motivos do abandono à terapia fonoaudiológica no contexto da Atenção Básica, tais como: incompatibilidade de horário, dinâmica dos atendimentos, observação de melhora/resolução do caso, desmotivação do paciente e necessidade de realizar tratamento prévio em outra área. CONCLUSÃO: foi possível observar a presença de distintos motivos relacionados ao abandono numa mesma entrevista, aspecto que corrobora com o apontado pela literatura nacional e internacional, que caracteriza o processo de adesão/não-adesão como complexo e multifatorial.

Impact of use of alcohol and illicit drugs by AIDS patients on adherence to antiretroviral therapy in Bahia, Brazil

Use of alcohol and illicit drugs is a common finding among HIV-infected individuals, but there are many open questions about its impact on adherence to antiretroviral therapy and virological outcomes. Our study aimed to evaluate the impact of the use of alcohol and illicit drugs on the adherence to antiretroviral therapy (ART) among patients starting ART in Salvador, Brazil. We followed up 144 AIDS patients initiating ART for a 6-month period. At baseline, they were interviewed about demographics, behavior, and use of illicit drugs and alcohol. All of them had HIV-1 RNA plasma viral load and CD4(+)/CD8(+) cells count measured before starting therapy. After 60 days of treatment they were asked to answer a new questionnaire on adherence to ART. All patients were monitored during the following months, and new CD4(+) cell count/HIV-1 RNA plasma viral load determinations were performed after 6 months of therapy. Optimal adherence to therapy was defined by self-reported questionnaire, by 95% use of prescribed drug doses, and by using plasma HIV-1 RNA viral load as a biological marker. A total of 61 (42.4%) patients reported alcohol use, 7 (4.9%) used illicit drugs, and 17 (11.8%) used both alcohol and illicit drugs. Being in a steady relationship was protective to nonadherence (95% CI: 0.18-0.84). Missing more than two medical visits was also associated with a 68% higher likelihood of nonadherence (95% CI: 0.10-1.02). After logistic regression we detected a higher risk of nonadherence for patients declaring use of alcohol plus illicit drugs (odds ratio=6.0; 95% CI: 1.78-20.28) or high-intensity use of alcohol (odds ratio=3.29; 95% CI: 1.83-5.92). AIDS patients using alcohol and/or illicit drugs are socially vulnerable, and need specific and flexible programs, combining mental health care, harm reduction strategies, and assisted drug therapy to maximize the chances of successful use of ART.