Evaluation of inadequate anti-retroviral treatment in patients with HIV/AIDS

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

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.

[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.

HIV/AIDS case definition criteria and association between sociodemographic and clinical aspects of the disease reported in the State of Minas Gerais from 2007 to 2016

INTRODUCTION

Over 30 years after the acquired immunodeficiency syndrome epidemic, several strategies have been implemented to verify the trend of the infection, the profile of the affected individuals, and the impact of prevention and control measures, with notification of asymptomatic carriers being the most recent measure. This study aimed to verify the geographic distribution of human immunodeficiency virus/acquired immunodeficiency syndrome and analyze the association between case definition criteria, sociodemographic data, and clinical aspects of the disease in the State of Minas Gerais between 2007 and 2016.

METHODS

In this ecological and analytical study, 35,349 cases of human immunodeficiency virus/acquired immunodeficiency syndrome reported in the State of Minas Gerais between 2007 and 2016 were analyzed. The data were analyzed using multiple correspondence factor analysis, time series analysis, descriptive statistics, and spatial distribution of the cases by macro-region.

RESULTS

The majority of the patients were brown-skinned individuals, alive, diagnosed with human immunodeficiency virus/acquired immunodeficiency syndrome on the basis of the criteria adapted from the Centers for Disease Control and Prevention, and living in municipalities with more than 50,000 (80.5%) inhabitants. Between 2007 and 2016, there was an increase in the number of criteria used for diagnosing human immunodeficiency virus. By contrast, a consequent decrease was observed in the number of criteria used for defining cases, which were adapted from the Centers for Disease Control and Prevention, Rio de Janeiro/Caracas, and for identifying AIDS-related deaths. Young people aged between 13 and 29 years, individuals whose education level is compatible with the observed age, and homosexual men were associated with the HIV+ criterion.

CONCLUSIONS

Out study showed that after the mandatory notification of human immunodeficiency virus-positive cases in 2014, there was a decrease in other criteria for defining human immunodeficiency virus/acquired immunodeficiency syndrome cases and changes in the profile of people living with human immunodeficiency virus/acquired immunodeficiency syndrome.

Monitoring self-reported adherence to antiretroviral therapy in public HIV care facilities in Brazil: A national cross-sectional study

INTRODUCTION

Patient adherence to antiretroviral therapy (ART) is critical for HIV treatment success. Monitoring rates of adherence in public HIV outpatient care facilities can improve outcomes in Brazil where ART is universally available.

METHODS

We conducted a national cross-sectional survey of ART adherence in 2010. Participants were selected using a multistage probability sample. First, HIV outpatient care facilities were stratified according to 7 Organizational Quality Classification (OQC) groups and regions. Second, 1 or 2 facilities were selected per region for each OQC group. Finally, patients were randomly selected at each facility. In a first component, patients were invited to answer to a web-based questionnaire (WebAd-Q), a validated self-reported tool that includes 3 questions on adherence to ART in the past 7 days (time scheduling-timing, drug regimen-medication, and pill counts-dose), herein named indicators of potential nonadherence (IPN). In addition, a subsample of participants were interviewed in order to obtain further data on sociodemographic and clinical characteristics (second component). The proportion of each IPN was estimated using weighted data to account for the sampling design with 95% confidence interval (CI) and descriptive analysis was carried out.

RESULTS

Fifty-five facilities were chosen and 2424 patients completed the WebAd-Q in the first component of the study, while 598 patients were interviewed for the second component. The weighted proportions of the IPN were 50.9%, 31.8%, and 19.5%, for timing, medication, and dose, respectively, while11.7% had all 3 indicators, varying from 5.9% in the Southeast and 21.9% in the Northeast regions. Overall, 61.1% of the patients had at least 1 IPN (95% CI: 58.5-63.7%). Patients reporting depression symptoms, illicit drug use and those who missed medical appointments had worse nonadherence outcomes.

CONCLUSIONS

Overall, there was a high proportion of all indicators IPN and timing was the main component associated with low adherence. Although these indicators may not necessarily indicate individual nonadherence, they represent a worrisome scenario in the public Brazilian HIV care facilities. On a routine basis, these facilities can identify gaps in providing counseling and ART orientation to their clientele and develop innovative strategies to prevent nonadherence.

Treatment adherence in patients living with HIV/AIDS assisted at a specialized facility in Brazil

INTRODUCTION

In the 1990s, Brazil adopted a public policy that allowed for universal, free access to antiretroviral therapy (ART). Since then, treatment adherence has become a new challenge for administrators of sexually transmitted disease/acquired immunodeficiency syndrome (STD/AIDS) policies. This study quantified adherence to ART and verified whether there is an association between sociodemographic variables and clinical/laboratory data in human immunodeficiency virus (HIV)-infected patients.

METHODS

This was a cross-sectional, exploratory study with a quantitative approach that was conducted over 8 months. The target population contained patients who were assisted at the ambulatory care facility specialized in STD/AIDS of a medium-size city located in Northwest São Paulo. In order to verify the level of adherence to ART, a validated CEAT-VIH (Assessment of Adherence to Antiretroviral Therapy Questionnaire) questionnaire was used. Sociodemographic aspects and clinical/laboratory data were obtained from the medical records. The results were analyzed using the Student's t-test and Pearson's coefficient.

RESULTS

Herein, 109 patients were interviewed, 56% of whom were male. The age of the population ranged 18-74 years (mean 45.67 years). Adherence to ART was classified as insufficient in 80.7% of cases. There was an association between ART adherence and presence of symptoms and/or opportunistic infection (p=0.008) and economic status (p<0.001).

CONCLUSIONS

Adherence to ART among HIV carriers cared for by the public health system is low. Patients who reported a favorable economic status and those without symptoms and/or opportunistic infection demonstrated greater treatment adherence than those who needed to take more than 3 pills a day.

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.

SOCIAL SUPPORT FOR PEOPLE LIVING WITH ACQUIRED IMMUNODEFICIENCY SYNDROME

ABSTRACT The aim of this study was to evaluate the social support for people with AIDS. It was a cross-sectional study, with 215 outpatients at a University Hospital in Northeastern Brazil. Data were collected from August to December 2012, through interviews, using a Socio-demographic and Clinical Form and a Social Support Scale for People Living with HIV/AIDS. Statistical Package for the Social Science was used for data analysis. Results showed that average scores of social emotional and instrumental support were satisfactory and not influenced by sex (p=0.954; p=0.508), education (p=0.756; p=0.194), marital status (p=0.076; p=0.446) and length of antiretroviral therapy (p=0.480; p=0.120). People diagnosed for less than three years had more instrumental support (p=0.048) than those diagnosed over three years (p=0.370). Neighbors, employers and health professionals provided less support. The conclusion was that people with AIDS have satisfactory social support, especially from friends and family not living in the same household.

Factors associated with non-adherence to antiretroviral therapy in adults with AIDS in the first six months of treatment in Salvador, Bahia State, Brazil

The control of viral replication is essential in the highly active antiretroviral therapy (HAART), and adherence to therapy is instrumental for such control. Individual and external factors influence adhesion to the use of antiretroviral (ARV) drugs. This is a cross-sectional study to investigate factors associated with non-adherence to HAART in AIDS patients in Salvador, Bahia State, Brazil, with age ≥ 13 years and first prescription in 2009. Data was collected from patient charts and pharmacy records. From a total of 216 patients, 65.3% were males; mean age 37.8 ± 9.5 years; single, 67.9%; heterosexual, 64%; more than 8 years of school education, 65.3%; alcohol users, 61.5%; non-smokers, 75,1% or non-illicit drug users, 93.7%. A proportion of 94% started ARV therapy with TCD4+ < 350 cells/mm3; 61.8% were symptomatic; and 68.4% had an adverse drug reaction. The prevalence of non-adherence was 25%. The variables associated were: longer time between HIV infection and AIDS (aOR = 3.9), adverse drug reaction (aOR = 2.4), under 34 years of age (aOR = 2.2), less than 8 years of school education (aOR = 2.2) and illicit drugs use (aOR = 2.6). A high-non-adherence rate is an important problem within the first six months of HAART.

Disseminated histoplasmosis in HIV-infected patients: determinants of relapse and mortality in a north-eastern area of Brazil

Many relapses and deaths resulting from disseminated histoplasmosis (DH) in acquired immunodeficiency syndrome (AIDS) patients have been observed in an endemic area in north-eastern Brazil. The objective of this study was to evaluate the risk factors associated with the clinical outcomes of DH/AIDS coinfection in patients from the state of Ceará, Brazil. A retrospective cohort of AIDS patients, after their hospital discharge due to first DH episode in the period 2002-2008, was followed until December 31, 2010, to investigate the factors associated with relapse and mortality. A total of 145 patients were evaluated in the study. Thirty patients (23.3%) relapsed and the overall mortality was 30.2%. The following variables were significantly (P < 0.05) associated with relapse and overall mortality (univariate analysis): non-adherence to highly active antiretroviral therapy (HAART), irregular use of an antifungal, non-recovery of the CD4+ count and having AIDS before DH; histoplasmosis relapse was also significantly associated with mortality. In the multivariate analysis, non-adherence to HAART was the independent risk factor that was associated with both relapse (Adj OR = 6.28) and overall mortality (Adj OR = 8.03); efavirenz usage was discovered to be significant only for the overall mortality rate (Adj OR = 4.50). Adherence to HAART was the most important variable that influenced the outcomes in this specific population.

Immunovirological parameters and cytokines in HIV infection

Although modern combined antiretroviral therapies (cART) result in lower morbidity and mortality and a visible improvement of clinical and laboratory parameters in HIV-infected, it is known that their long-term use contributes to appearance of the many events unrelated to AIDS such as cardiovascular diseases, cancer and osteoporosis, comorbidities which have been proposed as some of the most important that deprive the majority of infected to present an even better prognosis. This is because even with a decrease in inflammation and immune activation after drug intervention to the patient, these parameters remain higher than those shown by healthy individuals and the imbalance of cytokine profiles also persists. Therefore, evaluations of other biomarkers in clinical practice are needed to complement the exams already carried out routinely and allow more effective monitoring of HIV patients. This review aims to investigate the role of cytokines as potential markers showing studies on their behavior in various stages of HIV infection, with or without cART.