News nr. 26 | February/March 2012
Research and Advanced Education
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14th Programme “Education through Science”

The patient, the clinical situation and the relationship with health services – 
an analysis of adherence to antiretroviral therapy by HIV-1 seropositive individuals

Project number 201100023

Tutor: Dr. Paulo Nicola 
Students:  Maria Emília Pereira, Rita Martins, Violeta Nogueira
Co-tutor: Dr. Milene Fernandes 

Part of the ATAR-VIH project– Adherence to Antiretroviral Therapy by HIV seropositive individuals
(M Fernandes, L Caldeira, E Valadas, P Nicola, P Nogueira, AP Martins, V Maria) 

The patient, the clinical situation and the relationship with health services – an analysis of adherence to antiretroviral therapy by HIV seropositive individuals

• Introduction
Adherence to Antiretroviral Therapy (ART) is a major determinant for controlling HIV/AIDS (1).Given it is a multifactorial and complex behaviour, it is important to evaluate the role of individual characteristics as factors associated with adherence to ART.

Figure 1. Conceptual Model

• Objectives To identify determinants of adherence to ART among psychosocial factors, namely socio-demographic characteristics, satisfaction with social support and anxiety/depression.

• Methods We conducted a prospective observational cohort study on a systematic sample of adults infected with HIV-1 on ART who were being monitored at the Day Hospital for Infectious Diseases of Santa Maria Hospital and who had at least one medical appointment in the 3 months of recruitment. 


The Adherence to Antiretroviral Therapy was evaluated based on the Adherence to Therapy Evaluation Questionnaire (Adult AIDS Clinical Trials Group), developed for self-assessment of adherence to therapy recently adhered to – last 4 days, weekend, and last 30 days – to minimize memory bias(2).

The Initial Questionnaire applied to participants also included the evaluation of: 

A. Socio-Demographic Characteristics 
B. Satisfaction with Social Support (SSSS), a scale that varies between 15 and 75 points; the higher the total value of the scale, the greater the satisfaction with social support.
C. The Illness Perception Questionnaire (IPQ), a set of three distinct sections with 9 Likert type sub-scales of 5 points; the higher the value obtained, the greater the agreement with the causal attribution.
D. Depression, Anxiety, and Stress (DASS), a set of three scales, each ranging from 0 to 21 points; higher scores correspond to more negative states.

Assistant physicians were equally asked to complete a form providing clinical information about the consultation where the patient was invited to participate in the study. The association of adherence with other factors was evaluated using Student t- tests (continuous variables) and chi-square (categorical variables) assuming a=0,05.

• Results
Of a total of 306 individuals (Table 1) who had had a medical appointment during the recruitment period (May to July 2011), 203 eligible participants (participation rate: 66.3%) were included in the study. The most frequent causes for non-eligibility were the fact that patients came from other hospitals (12.1%), were infected with HIV -2 (4.2%), did not have the capacity to provide informed consent (3.3%), and were not on ART (3.0%). The refusal rate was 8.8%. 

Table 1. Main socio-demographic and clinical characteristics of participants included in the study (n=203)

Of the 195 participants (Table 2) who answered all the questions in the questionnaire, 89 (45.6%) were classified as non-compliant and 172 (88.3%) reported never having missed taking antiretroviral medication in the past 7 days.

It was noted that non-compliance was associated with excessive consumption of alcohol in a short period of time <4 hours (“binge drinking”) (p=0.001) and higher scores in the depression (p=0.032) and anxiety (p=0.002).scales

Table.2 Factors associated with antiretroviral therapy

• Discussion 

Demographic characteristics
and transmission routes are consistent with the official national epidemiological data for 2010, with a percentage of male individuals being slightly lower in our study (75.4% vs. 81.1% in the official statistics).

Concerning factors related to individuals, it was found that socio-demographic variables did not influence adherence. This result may be partly explained by the smaller sample size in this study, which in turn was based on a population of predominantly European origin and with similar access to medication.

With regard to the patient’s clinical condition, we noted that the presence of non-infectious co-morbidities is associated with lower adherence, namely depression. On the other hand, the excessive consumption of alcohol in <4hours, anxiety, beliefs about HIV infection, and the capacity to take medication were identified as factors associated with non-compliance.

It must be stressed that the influence of the individual’s relationship with the various players in the health services, namely the doctor, could be subject to more thorough evaluation, which will be conducted in the six-month period of follow up of these participants.

Assessment of adherence using another objective method (i.e., registration of exemption of medication) and not only by self-report is also one of the things to verify when continuing this project. 

• Conclusion 

The present study draws attention to the high prevalence of non-adherence and strengthens the need for clarification of the factors associated with it. It is important to develop adapted strategies such as, for example, psychological/psychiatric support to risk behaviours, such as the imbalanced intake of alcohol, depression and anxiety; development of training sessions/awareness raising sessions in order to change individuals’ misinterpretations regarding the disease and the ability to take medication, among others. It is the doctor’s responsibility to identify these situations for appropriate referral. The factors that have been identified are target areas for intervention and show the need for a multidisciplinary-follow up of individuals in order to better use ART

• Future prospects 
In future, it would be interesting to conduct longer multi-centred studies indicating which are the most important factors in adherence, both in the short and medium term, and the importance of factors related to health care provided by distinct national hospitals

• Acknowledgements 
To the participants and the team of the Day Hospital for Infectious Diseases of Santa Maria Hospital
To the research team of the ATAR-HIV study and colleagues conducting GAPIC projects associated with this study.
To the 14th Education through Science Programme.
The ATAR-HIV study was sponsored by the Merck, Sharp & Dohme Foundation, which had no implications on the data presented here. 

_____________(1)Lian YL, et al. AIDS-defining illnesses: A comparison between before and after commencement of highly active antiretroviral therapy (HAART). Curr HIV Res 2007;5(5):484-489.
(2)Chesney MA, et al. Self-reported adherence to antiretroviral medications among participants in HIC Clinical Trials: the AACTG Adherence Instruments. AIDS Care 2000;12(3): 255-266.
(3)Doutor Ricardo Jorge Institute. Department of Infectious Diseases, referral and epidemiological vigilance unit. Infection by HIV/AIDS, the situation in Portugal, 31st December 2010. Lisbon, February 2011., accessed in 2011/10/21

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Prof. Doutor J. Fernandes e Fernandes
Editorial Commitee: Prof. Doutor J. Fernandes e Fernandes, Prof. Doutor Alexandre Ribeiro, Prof. Doutor António Vaz Carneiro, Prof. Doutor João Ferreira, Dr. Luis Pereira
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