t and a reduction in morbidity and mortality of the infected patients.

However, high levels of adherence are required to obtain virologic

suppressioDepartamento de Medicina, Salvador, BA, Brazil

articleinfo

Article history: Received 12 December 2016

Accepted 17 April 2017 Available online xxx
The Brazilian Journal of

INFECTIOUS Keywords: Highly active antiretroviral therapy

HIV/AIDS Adherence Nonadherence Anxiety
DISEASES Depression Quality of life
abstract
abstract
The introduction of highly active antiretroviral
therapy marked a major gain in efficacy of
Original article HIV/AIDS treatmenn. In Brazil, the policy of
free and universal access to antiretroviral
Quality of life, anxiety and therapy has been in place since 1996, although
there are reports of poor adherence. Objective:
depression in patients with To define the clinical, demographic and
HIV/AIDS who present poor psychological characteristics, and quality of life
of patients with HIV/AIDS who present poor
adherence to antiretroviral adherence to highly active antiretroviral therapy.
therapy: a cross-sectional Methods: This was a cross-sectional study. To
be included in the study patients had to be 18
study in Salvador, Brazil through 65 years old, diagnosed with
HIV/AIDS, having the two previous viral loads
Q1
above 500 copies, a surrogate for poor
Mónica Narváez Betancur a, Liliane Linsb, adherence to antiretrovirals. The following
instruments were applied to all eligible patients:
Irismar Reis de Oliveirab, Carlos Brites
the sociodemographic questionnaire
a,b,∗
a Universidade Federal da Bahia (UFBA) Programa de “Adherence Follow-up Questionnaire”, the
Pós-Graduac ̧ão em Medicina e Saúde, Salvador, BA, Brazil b Beck Depression Inventory (BDI-II), the Beck
Universidade Federal da Bahia (UFBA), Faculdade de Medicina,
Anxiety Inventory (BAI), and the 36-Item Short
Form Survey. Results: 47 patients were
Departamento de Medicina, Salvador, BA, Brazil
evaluated, 70.2% were female, mean age of
Mónica Narváez Betancur , Liliane Linsb,
a
41.9 years (±10.5), 46.8% were single, 51.1%
Irismar Reis de Oliveirab, Carlos Brites self-reported adherence ≥95%, 46.8%
a,b,∗
a Universidade Federal da Bahia (UFBA) Programa de mentioned depression as the main reason for not
Pós-Graduac ̧ão em Medicina e Saúde, Salvador, BA, Brazil b taking the medication, 59.5% presented
symptoms of moderate to severe depression,
Universidade Federal da Bahia (UFBA), Faculdade de Medicina,
and 44.7% presented symptoms of moderate to
severe anxiety. Finally, regarding health-related
quality of life these patients obtained low scores
in all dimensions, physical component summary
of 43.96 (±9.64) and mental component
summary of 33.19 (±13.35). Conclusion: The
psychological component is considered to be
fundamental in the manage- ment of HIV/AIDS
patients. Psychoeducation should be conducted
at the initial evaluation to reduce negative
beliefs regarding antiretroviral therapy
Assessment of anxiety and
The introduction of highly active antiretroviral
therapy marked a major gain in efficacy of
HIV/AIDS treatment and a reduction in
morbidity and mortality of the infected patients.
However, high levels of adherence are required
to obtain virologic suppression. In Brazil, the
policy of free and universal access to
antiretroviral therapy has been in place since
1996, although there are reports of poor
adherence. Objective: To define the clinical,
demographic and psychological characteristics,
and quality of life of patients with HIV/AIDS
who present poor adherence to highly active
antiretroviral therapy. Methods: This was a
cross-sectional study. To be included in the
study patients had to be 18 through 65 years old,
diagnosed with HIV/AIDS, having the two previous viral
loads above 500 copies, a surrogate for poor adherence to
antiretrovirals. The following instruments were applied to all eligible
patients: the sociodemographic questionnaire “Adherence Follow-up
Questionnaire”, the Beck Depression Inventory (BDI-II), the Beck
www.elsevier.com/locate/bjid
Anxiety Inventory (BAI), and the 36-Item Short Form Survey. Results:
47 patients were evaluated, 70.2% were female, mean age of 41.9 years
(±10.5), 46.8% were single, 51.1% self-reported adherence ≥95%,
46.8% mentioned depression as the main reason for not taking the
medication, 59.5% presented symptoms of moderate to severe
depression, and 44.7% presented symptoms of moderate to severe
anxiety. Finally, regarding health-related quality of life these patients
obtained low scores in all dimensions, physical component summary of
43.96 (±9.64) and mental component summary of 33.19 (±13.35).
Conclusion: The psychological component is considered to be
fundamental in the manage- ment of HIV/AIDS patients.
Psychoeducation should be conducted at the initial evaluation to reduce
negative beliefs regarding antiretroviral therapy Assessment of anxiety
and
The introduction of highly active antiretroviral therapy marked a major
gain in efficacy of HIV/AIDS treatment and a reduction in morbidity
and mortality of the infected patients. However, high levels of
adherence are required to obtain virologic suppression. In Brazil, the
policy of free and universal access to antiretroviral therapy has been in
place since 1996, although there are reports of poor adherence.
Objective: To define the clinical, demographic and psychological
characteristics, and quality of life of patients with HIV/AIDS who
present poor adherence to highly active antiretroviral therapy.
Methods: This was a cross-sectional study. To be included in the study
patients had to be 18 through 65 years old, diagnosed with HIV/AIDS,
having the two previous viral loads above 500 copies, a surrogate for
poor adherence to antiretrovirals. The following instruments were
applied to all eligible patients: the sociodemographic questionnaire
“Adherence Follow-up Questionnaire”, the Beck Depression Inventory
(BDI-II), the Beck Anxiety Inventory (BAI), and the 36-Item Short
Form Survey. Results: 47 patients were evaluated, 70.2% were female,
mean age of 41.9 years (±10.5), 46.8% were single, 51.1%
self-reported adherence ≥95%, 46.8% mentioned depression as the
main reason for not taking the medication, 59.5% presented symptoms
of moderate to severe depression, and 44.7% presented symptoms of
moderate to severe anxiety. Finally, regarding health-related quality of
life these patients obtained low scores in all dimensions, physical
component summary of 43.96 (±9.64) and mental component summary
of 33.19 (±13.35). Conclusion: The psychological component is
considered to be fundamental in the manage- ment of HIV/AIDS
patients. Psychoeducation should be conducted at the initial evaluation
to reduce negative beliefs regarding antiretroviral therapy Assessment
of anxiety and
∗ Corresponding author.
E-mail address: crbrites@gmail.com (C. Brites). http://dx.doi.org/10.1016/j.bjid.2017.04.004 1413-8670/© 2017 Sociedade Brasileira de Infectologia.
Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

ARTICLE IN PRESS BJID 736 1–8

braz j infect dis 2 0 1 7;x x x(x x):xxx–xxx
antiretroviral therapy: a cross-sectional study in Salvador, Brazil. Braz J Infect Dis. 2017. http://dx.doi.org/10.1016/j.bjid.2017.04.004
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768697071727374757677
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PRESS 2 b r a z j i n f e c t d i s . 2 0 1 7;x x x(x
x):xxx–xxx
depression symptoms should be done throughout therapy as both
psycological conditions are associated with patient adherence, success
of treatment, and ultimately with patients’ quality of life.
© 2017 Sociedade Brasileira de Infectologia. Published by Elsevier
Editora Ltda. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
The introduction of highly active antiretroviral therapy (HAART)
in the 1990s marked a major gain in HIV/AIDS treat- ment
efficacy, and a reduction in morbidity, mortality, and quality of life
of these patients. In Brazil, the policy of free and universal access
to antiretroviral therapy1 has been in place since 1996. Currently,
the recommendation is for early onset of HAART, due to the
benefits for people living with HIV/AIDS as well as for viremia
control.2,3
However, in order for HAART to be successful, adherence is
crucial and is strictly associated with virologic suppression.4,5
Therefore, the efficacy of HAART depends on maintaining high
rates of treatment adherence, considered in most of the sci- entific
literature as adherence equal to or greater than 95% of the
6
prescribed dosages. Although the more potent drug regi- mens
currently used allow for moderate adherence levels, no regimen
allows for a partial adherence.7
Low levels of adherence increase disease progression as well as
viral resistance, and limit the therapeutic options. In Brazil,
between 1999 and 2008, there were reports of poor adherence to
HAART, varying between 23.3% and 36.9%.8–10
Adherence is a complex dynamic and multifactorial process that
encompasses physical, psychological, social, cul- tural, and
behavioral aspects.2 Therefore, there are diverse challenges faced
by people living with HIV/AIDS associated with the difficulties in
maintaining high and prolonged levels of therapeutic adherence. In
previous studies on the factors associated with poor adherence, the
following were empha- sized: depression, anxiety, low social
support, complexity of therapeutic regimen, relationship with
medical personnel, low level of schooling, side effects, negative
beliefs about the treatment, stigma, and alcohol/substance
abuse.2,11
In short, the predictive factors of nonadherence may be grouped as
follows: patient characteristics, the pre- scribed treatment regimen,
the characteristics of the disease, doctor-patient relationship, and
the location of medical care delivery.12,13 Thus, the initial
challenge for the managers of national policies and health care
services specialized in HIV/AIDS is to understand how all these
factors influence patient adherence, in order to establish effective
actions, adjusted to the population characteristics. Furthermore,
there are few studies in Brazil that evaluate the factors associated
with low adherence and the quality of life of patients undergo- ing
HAART.14,15 Therefore, the main objective of this study was to
define the clinical-demographic and psychological charac- teristics
as well as quality of life and beliefs about HAART of the patients
who present poor adherence to HAART, and eval- uate the relation
of some of these characteristics to adherence and quality of life.
Materials and methods
Materials and methods
Study setting
Study setting
This study was conducted at the Prof. Edgard Santos Univer- sity
Hospital (HUPES), Salvador, Bahia, Brazil, a reference cen- ter
that provides health care services at the outpatient clinic or by
hospitalization, for patients with HIV/AIDS diagnosis.
This study was conducted at the Prof. Edgard Santos Univer- sity
Hospital (HUPES), Salvador, Bahia, Brazil, a reference cen- ter
that provides health care services at the outpatient clinic or by
hospitalization, for patients with HIV/AIDS diagnosis.
Study design and population
Study design and population
This study was a cross-sectional study carried out between
February and May of 2016. Patients with HIV, on antiretro- viral
therapy for at least one year, aged between 18 and 65 years,
receiving care at the AIDS outpatient clinics, having the last two
viral loads above 500 copies, and who could read and write were
invited to participate. Patients who presented neu- rocognitive
impairment or psychotic disturbances that could compromise their
understanding of the study were excluded. During the study
period, 1395 patients with an HIV/AIDS diagnosis looked for care
at the HUPES outpatient clinic; of these, 898 were male and 497
were female, and had their medical records were checked for the
eligibility criteria con- sidered. A total of 1331 patients did not
meet the inclusion criteria thus leaving 64 patients to be studied.
However, 17 (26%) patients refused to participate remaining 47
(73.4%) to be evaluated (Fig. 1).
This study was a cross-sectional study carried out between
February and May of 2016. Patients with HIV, on antiretro- viral
therapy for at least one year, aged between 18 and 65 years,
receiving care at the AIDS outpatient clinics, having the last two
viral loads above 500 copies, and who could read and write were
invited to participate. Patients who presented neu- rocognitive
impairment or psychotic disturbances that could compromise their
understanding of the study were excluded. During the study
period, 1395 patients with an HIV/AIDS diagnosis looked for care
at the HUPES outpatient clinic; of these, 898 were male and 497
were female, and had their medical records were checked for the
eligibility criteria con- sidered. A total of 1331 patients did not
meet the inclusion criteria thus leaving 64 patients to be studied.
However, 17 (26%) patients refused to participate remaining 47
(73.4%) to be evaluated (Fig. 1).
This study was a cross-sectional study carried out between
February and May of 2016. Patients with HIV, on antiretro- viral
therapy for at least one year, aged between 18 and 65 years,
receiving care at the AIDS outpatient clinics, having the last two
viral loads above 500 copies, and who could read and write were
invited to participate. Patients who presented neu- rocognitive
impairment or psychotic disturbances that could compromise their
understanding of the study were excluded. During the study
period, 1395 patients with an HIV/AIDS diagnosis looked for care
at the HUPES outpatient clinic; of these, 898 were male and 497
were female, and had their medical records were checked for the
eligibility criteria con- sidered. A total of 1331 patients did not
meet the inclusion criteria thus leaving 64 patients to be studied.
However, 17 (26%) patients refused to participate remaining 47
(73.4%) to be evaluated (Fig. 1).
This study was a cross-sectional study carried out between
February and May of 2016. Patients with HIV, on antiretro- viral
therapy for at least one year, aged between 18 and 65 years,
receiving care at the AIDS outpatient clinics, having the last two
viral loads above 500 copies, and who could read and write were
invited to participate. Patients who presented neu- rocognitive
impairment or psychotic disturbances that could compromise their
understanding of the study were excluded. During the study
period, 1395 patients with an HIV/AIDS diagnosis looked for care
at the HUPES outpatient clinic; of these, 898 were male and 497
were female, and had their medical records were checked for the
eligibility criteria con- sidered. A total of 1331 patients did not
meet the inclusion criteria thus leaving 64 patients to be studied.
However, 17 (26%) patients refused to participate remaining 47
(73.4%) to be evaluated (Fig. 1).
Assessments
Assessments
Sociodemographic characteristics
Sociodemographic characteristics
A structured questionnaire was developed for the study aimed at
obtaining the participants’ sociodemographic information: gender,
age, ethnicity, marital status, sexual orientation, edu- cation,
occupation, and types of support. Furthermore, they were asked
questions related to their habits and health condi- tions, such as
year of diagnosis and when they began HAART, other chronic
illnesses, alcohol consumption, use of psychoac- tive drugs, and
medical assistance. Their medical records were reviewed to obtain
information on the most recent viral load and the CD4+
lymphocyte count.
A structured questionnaire was developed for the study aimed at
obtaining the participants’ sociodemographic information: gender,
age, ethnicity, marital status, sexual orientation, edu- cation,
occupation, and types of support. Furthermore, they were asked
questions related to their habits and health condi- tions, such as
year of diagnosis and when they began HAART, other chronic
illnesses, alcohol consumption, use of psychoac- tive drugs, and
medical assistance. Their medical records were reviewed to obtain
information on the most recent viral load and the CD4+
lymphocyte count.
A structured questionnaire was developed for the study aimed at
obtaining the participants’ sociodemographic information: gender,
age, ethnicity, marital status, sexual orientation, edu- cation,
occupation, and types of support. Furthermore, they were asked
questions related to their habits and health condi- tions, such as
year of diagnosis and when they began HAART, other chronic
illnesses, alcohol consumption, use of psychoac- tive drugs, and
medical assistance. Their medical records were reviewed to obtain
information on the most recent viral load and the CD4+
lymphocyte count.
Adherence
Adherence
Two questionnaires were used to measure adherence: (1)
“Adherence Follow-up Questionnaire” from the Aids Clinical
Trial Groups (ACTG),16 translated to Portuguese17 to assess
self-reported adherence in the previous four days, use of pills by
dosage and reasons for not taking the drugs; and (2) a
questionnaire on knowledge and beliefs related to AIDS and
Two questionnaires were used to measure adherence: (1)
“Adherence Follow-up Questionnaire” from the Aids Clinical
Trial Groups (ACTG),16 translated to Portuguese17 to assess
self-reported adherence in the previous four days, use of pills by
dosage and reasons for not taking the drugs; and (2) a
questionnaire on knowledge and beliefs related to AIDS and
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Please cite this article in press as: Betancur MN, et al. Quality of life, anxiety and depression in patients with HIV/AIDS who present poor
BJID 736 1–8 adherence to
antiretroviral therapy: a cross-sectional study in Salvador, Brazil. Braz J Infect Dis. 2017. http://dx.doi.org/10.1016/j.bjid.2017.04.004
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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 – Summary of the selection process of HIV-AIDS patients presenting poor adherence to HIV therapy in Salvador-Brazil.
to HAART, developed by the same group and translated to Por- tuguese by a previous study.18
Adherence was calculated as the number of doses that were effectively taken divided by the number of prescribed doses in the previous four days.
Participants with adherence greater or equal to 95% were considered as being adherent.
Depression
The Beck Depression Inventory II (BDI-II) in the Portuguese version19,20 was used to measure depression symptoms. The BDI-II is a self-reported
scale with 21 items, each one with four choices of answer that imply increasing levels of depression severity. The total score is the sum of the
individual scores of the items and provides the classification of the intensity of depression as minimal, mild, moderate, or severe.
Anxiety
The Beck Anxiety Inventory (BAI), Portuguese version,20 com- prising 21 items or anxiety symptom affirmations that are evaluated by the subject
on a scale of four points related to the levels of increasing severity of each symptom, was used to assess the anxiety symptoms of the patients. The
total score is the sum of the individual scores of the items and provides the classification of the intensity level of anxiety as minimal, mild,
moderate, or severe.
Quality of life
To estimate quality of life, the 36-item Short Form Health Survey (SF-36), Portuguese version21 was chosen. This
questionnaire has 36 questions that measure quality of life related to health in eight dimensions: Physical Functioning, Physical Role, Bodily Pain,
General Health, Vitality, Social Func- tioning, Emotional Role, and Mental Health. Furthermore, the questionnaire allows for evaluations of the
physical compo- nent summary as well as the mental component summary.
Statistical analysis
The descriptive analyses of the qualitative variables were presented in absolute and relative frequencies. Continuous variables with normal
distribution (age) were presented as mean and standard deviation. Continuous variables without normal distribution (years since diagnosis, years
of treatment, number of pills, viral load, and CD4+ lymphocyte count) were expressed as median, minimum and maximum. Scores of quality of
life were compared between genders and between those who had or had not used antiretroviral drugs in the last month by the Mann–Whitney
nonparametric test.
Furthermore, the depression and anxiety variables were 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 quality of
life were carried out using the Mann–Whitney nonparametric test. In the same way, Pearson’s chi-squared test was used to evaluate whether the
intensity of anxiety and depression symptoms were associated with the partic- ipants’ gender, and also whether the most relevant reason reported
by the participants for stopping HAART was asso- ciated with the intensity of depression symptoms. A p-value less than 0.05 was considered
statistically significant. The
Please cite this article in press as: Betancur MN, et al. Quality of life, anxiety and depression in patients with HIV/AIDS who present poor
BJID 736 1–8 adherence to
antiretroviral therapy: a cross-sectional study in Salvador, Brazil. Braz J Infect Dis. 2017. http://dx.doi.org/10.1016/j.bjid.2017.04.004
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Statistical Package for the Social Sciences (SPSS) version 20.0 for Windows was used.
Ethical considerations
The present study was approved by the Research Ethics Com- mittee of the School of Medicine of the Federal University of Bahia, in August of
2015 (case number 1.154.393). All partici- pants signed a written consent form.
Results
The sociodemographic characteristics of the participants are presented in Table 1. Of the 47 participants, 70.2% were
Table 1 – Sociodemographic characteristics of the participants with HIV/AIDS who present poor adherence to HAART, in Salvador,
Bahia, 2016.
Variables Total n = 47 (%)
Female sex 33 (70.2) Age (years) (mean, Ds) 41.9 (±10.5)
Ethnicity
Black 22 (46.8) Racially mixed 13 (27.7) White 10 (21.3) Indigenous 2 (4.3)
Education
Elementary school, complete/incomplete 22 (46.8) High school, complete/incomplete 25 (53.2)
Marital status
Single 22 (46.8) Married/living with partner 19 (40.4) Divorced/widowed 6 (12.7)
Sexual orientation
Heterosexual 42 (89.4) Homosexual 4 (8.5) Bisexual 1 (2.1)
Individual income
Has individual income 25 (53.2) Has no individual income 22 (46.8) Early retirement due to illness 11 (23.4)
Family support
Support 39 (83) Reject 4 (8.6) No one knows the diagnosis 4 (8.6)
Type of supporta
Spiritual 23 (48.9) Emotional 7 (14.8) Therapeutic 5 (10.6) Financial 12 (25.5) No type of support 8 (17)
Alcohol
Consumed alcohol in the last three months 24 (51.1) Frequent alcohol consumption (at least
once a week)
female, mean age 41.9 years (±10.5), and 46.8% self-reported as being of black ethnicity. Regarding marital status, 46.8% were single and 40.4%
married; the majority (89.4%) was heterosex- ual. Only 53.2% had an individual income, and of these 23.4% reported the income originated from
disability/retirement insurance payment related to illness. In the realm of social support, 91.6% of the participants reported that the family was
aware of the HIV diagnosis, and 83% reported having family support. Alcohol consumption in the last three months were admitted by 51.1%, with
21.3% having consumed at least once a week, and 14.9% had heavy alcohol consumption, defined as five or more doses more than once a week.
Only 6.4% (all males) reported use of other psychoactive substances in addi- tion to heavy alcohol consumption.
The clinical and psychological characteristics are listed in Table 2. The mean number of years since diagnosis was 13.5 (minimum 2 and
maximum 28), and the average number of years on treatment was 13 (minimum 1 and maximum 20); at the time of evaluation the mean TCD4+
lymphocytes was 366 cells/μL (minimum 1 and maximum 970), and 80% of the participants presented a viral load between 400 and 100,000
copies. Moreover, among the participants who had other chronic diseases requiring medication, depression was the most common, with 31.2%. It
is relevant because 59.5% of all patients presented moderate to severe symptoms of depression, and 44.7% presented anxiety symptoms. That
means that only a minority were on treatment for such problems. An association was also found between stopping HAART due to feeling
depressed and moderate and severe
Table 2 – Clinical and psychological characteristics of participants with HIV/AIDS who present poor adherence to HAART, treated in
Salvador, Bahia, 2016.
Variables Total n = 47 (%)
Years since diagnosis (n = 45) (Md; min-max) 13.5 (2–28) Years of HAART (n = 40) (Md; min-max) 13 (1–20) Number of pills per day (Md; min-max) 3 (1–9)
Self-reported Adherence ≥ 95% 24 (51.1) CD4+ (Md; min-max) 366 (1–970)
Viral load (n = 45)
400–100,000 36 (80) 100,000 9 (20)
Other chronic diseases with medication 16 (34.0) Depression with medication 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)
10 (21.3)
Mild Moderate 15 (31.9) 13 (27.7)
Heavy alcohol consumption 7 (14.9)
Severe 8 (17.0)
Psychoactive substance consumption 3 (6.4)

a BeckDepression Inventory – BDI, Portuguese version. Minimal

Missed doctor’s appointment in the last 6 months 25 (53.2)

0–11, Mild 12–19, Moderate 20–35 and Severe 36–63. b Beck Anxiety Inventory – BAI, Portuguese version. Minimal 0–10, a Including family support.
Mild 11–19, Moderate 20–30 and Severe 31–63.
Please cite this article in press as: Betancur MN, et al. Quality of life, anxiety and depression in patients with HIV/AIDS who present poor
BJID 736 1–8 adherence to
antiretroviral therapy: a cross-sectional study in Salvador, Brazil. Braz J Infect Dis. 2017. http://dx.doi.org/10.1016/j.bjid.2017.04.004
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Feel well
44,7%
Fig. 2 – Reasons for stopping therapy among HIV/AIDS patients who present poor adherence to HAART, in Salvador, Brazil.
intensity of depression symptoms (p = 0.02). When evaluating the association of gender with anxiety and depression, an association was observed
between the female sex and mod- erate and severe anxiety symptoms (p = 0.006) but there was no association between gender and symptoms of
depression (p = 0.13).
Regarding adherence, although 51.1% of the participants presented adherence equal to or greater than 95% in the previ- ous four days, 57.4% did
not take some of the medication in the previous week, and 74.5% in the month prior. The most rele- vant reason for not taking HAART (Fig. 2)
was being depressed, with 46.8%, and other reasons were being away from home 44.7%; forgetfulness; avoiding undesired side effects, and tak-
ing the pills at specific times, with 38.3% each. On the other hand, even though 89.4% of the participants acknowledged that taking HAART helps
one remain healthy for a longer time, they also showed some negative beliefs related to the treat- ment: 89.4% believed that the side effects were
intense, 74.4% thought that taking HAART meant you had AIDS, and 72.3% had the belief that HAART was toxic (Table 3).
When evaluating quality of life related to health from a multidimensional approach, it was observed that the partic-
Table 3 – Beliefs about HAART of participants with HIV/AIDS, treated in Salvador, Bahia, 2016, who present poor adherence to
antiretroviral therapy.
Variables Total n = 47 (%)
Undergoing HAART is a good idea
even if you don’t have symptoms
17.0%
No more pills
14.9%
Specific hours to take meds
38.3%
Feel depressed
46.8%
Feel sick or indisposed
31.9%
Sleeping when time to take dose
29.8%
Feel the drug is toxic/harmful
17.0%
Change in daily routine
25.5%
Not being observed taking the meds
29.8%
Avoiding undesirable side effects
38.3%
Number of pills to take
17.0%
Forgetting
38.3%
Being busy with other things
29.8%
Being out of the house
0% 10% 20% 30% 40% 50%
ipants presented lower than expected (by scale’s reference values) mean scores in all the dimensions (Table 4), with the dimensions of the mental
component having the lowest score. Moreover, when comparing gender, women had lower scores in the dimensions of vitality (males: 47.9,
females: 37.2; p = 0.03), mental health (males: 40.2, females: 32.3; p = 0.008) and mental component summary (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 the dimensions of general health
(yes 39.2, not 50.9; p = 0.01) and bodily pain (yes 41.8, not 50.8; p = 0.01). When comparing intensity of anxiety and depression symptoms (Table
4), the patients who had moderate and severe symptoms of depres- sion or anxiety also had lower scores in all dimensions except depression with
bodily pain (p = 0.12) and anxiety with physi- cal functioning (p = 0.63), general health (p = 0.35) and physical component summary (p = 0.42).
Discussion
The aim of this study was to identify the relevant character- istics that might have been associated with non-adherence to treatment, in a group of
patients who presented poor adher- ence to HAART. During the time period of the study, 898 (64.4%) men and 497 (35.6%) women were treated
at the HUPES out- patient clinic. It is noteworthy that more women (33 subjects, 70% of sample) showed poor adherence to HAART. This result
37 (78.7)
is consistent with a study developed in Belo Horizonte, MG, that confirmed poorer adherence among women.23 Likewise,
HAART has demonstrated its efficacy 32 (68.0)
another multicentric study developed by the AIDS Clinical Tri-
By undergoing HAART a person will be
als Group in the United States, Puerto Rico and Italy24 reported healthy for longer
women as having a greater risk of virologic failure due to poor adherence. Nevertheless, there are other recent studies that did not find a
relationship between gender and levels of adherence.25,26 Moreover, a systematic review on differences of adherence according to gender found a
marginally signifi- cant difference of lower adherence in women.27 42 (89.4)
Side effects are intense for most
people
42 (89.4)
Undergoing HAART means you have
AIDS
35 (74.4)
HAART is toxic for most people 34 (72.3)
Please cite this article in press as: Betancur MN, et al. Quality of life, anxiety and depression in patients with HIV/AIDS who present poor
BJID 736 1–8 adherence to
antiretroviral therapy: a cross-sectional study in Salvador, Brazil. Braz J Infect Dis. 2017. http://dx.doi.org/10.1016/j.bjid.2017.04.004
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IN
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This study also investigated the participants’ beliefs about
HAART and the reasons for not using the treatment. Although
they admitted that HAART was effective and helped one to remain
healthy for a longer time, negative ideas related to side effects,
toxicity, and the concept that undergoing HAART meant one had
AIDS were also presented. A review article on adherence and
HAART demonstrated that the patient’s belief system about the
nature of the illness, its treatment, and the fears regarding side
effects may be important obstacles to adherence.6 It is noteworthy
that avoiding undesirable side effects was also one of the relevant
reasons reported by 38.3% of the participants for stopping
HAART, a finding that is near the 33.3% found in another
Brazilian study.28
High prevalence of depression and symptoms of depres- sion have
been widely demonstrated in the literature in patients with
HIV/AIDS. Prevalence studies reported a 28.1% in France,29
25.6% in the United States,30 and 32% in Brazil.31 Sev- eral
studies mention depression as one of the most important barriers
to adhering to HAART.6,32 In this study, we found that the reason
for stopping HAART because of feeling depressed was associated
with moderate and severe levels of depres- sion symptoms. This
finding is even more relevant when considering that feeling
depressed was the greatest reason reported by the participants for
stopping HAART and that most (59.5%) of them presented
clinically significant symptoms of depression.19,22
The percentage of participants who presented depressive
symptoms between moderate and severe (59.5%) was signif-
icantly higher than those from other Brazilian studies (18% and
21.5%),31,33 that evaluated patients with HIV who did not
necessarily have adherence issues as in this present study. In
addition, only 10.6% had prescriptions of antidepressive drugs.
Other studies mention that between 50% and 60% of the patients
with depression are undiagnosed.31
The rates of moderate and severe symptoms of anxiety were
higher in this study (44.7%) than in another previous study in
Brazil (35.8%), that detected symptoms of severe anx- iety
(12.6%) as an important predictor for non-adherence to HAART.33
Since our work was focused on a non-adherent
population, our results were expected, and reinforces the
importance of anxiety in the adherence process. A relation- ship
with the intensity of anxiety symptoms and female gender was
also observed, which is consistent with a study published in
2016.34 This also reinforces the importance of finding a high
proportion of women in our study.
population, our results were expected, and reinforces the
importance of anxiety in the adherence process. A relation- ship
with the intensity of anxiety symptoms and female gender was
also observed, which is consistent with a study published in
2016.34 This also reinforces the importance of finding a high
proportion of women in our study.
population, our results were expected, and reinforces the
importance of anxiety in the adherence process. A relation- ship
with the intensity of anxiety symptoms and female gender was
also observed, which is consistent with a study published in
2016.34 This also reinforces the importance of finding a high
proportion of women in our study.
population, our results were expected, and reinforces the
importance of anxiety in the adherence process. A relation- ship
with the intensity of anxiety symptoms and female gender was
also observed, which is consistent with a study published in
2016.34 This also reinforces the importance of finding a high
proportion of women in our study.
population, our results were expected, and reinforces the
importance of anxiety in the adherence process. A relation- ship
with the intensity of anxiety symptoms and female gender was
also observed, which is consistent with a study published in
2016.34 This also reinforces the importance of finding a high
proportion of women in our study.
population, our results were expected, and reinforces the
importance of anxiety in the adherence process. A relation- ship
with the intensity of anxiety symptoms and female gender was
also observed, which is consistent with a study published in
2016.34 This also reinforces the importance of finding a high
proportion of women in our study.
population, our results were expected, and reinforces the
importance of anxiety in the adherence process. A relation- ship
with the intensity of anxiety symptoms and female gender was
also observed, which is consistent with a study published in
2016.34 This also reinforces the importance of finding a high
proportion of women in our study.
Differences by gender were also observed in some dimen- sions of
quality of life: women had lower scores in the dimensions vitality,
mental health, and mental component summary, which might be
related to the fact that they had more symptoms of moderate and
severe anxiety than did men. In a previously published Brazilian
work it was found that women living with HIV and patients with
anxiety had worse quality of life scores.35
Differences by gender were also observed in some dimen- sions of
quality of life: women had lower scores in the dimensions vitality,
mental health, and mental component summary, which might be
related to the fact that they had more symptoms of moderate and
severe anxiety than did men. In a previously published Brazilian
work it was found that women living with HIV and patients with
anxiety had worse quality of life scores.35
Differences by gender were also observed in some dimen- sions of
quality of life: women had lower scores in the dimensions vitality,
mental health, and mental component summary, which might be
related to the fact that they had more symptoms of moderate and
severe anxiety than did men. In a previously published Brazilian
work it was found that women living with HIV and patients with
anxiety had worse quality of life scores.35
Differences by gender were also observed in some dimen- sions of
quality of life: women had lower scores in the dimensions vitality,
mental health, and mental component summary, which might be
related to the fact that they had more symptoms of moderate and
severe anxiety than did men. In a previously published Brazilian
work it was found that women living with HIV and patients with
anxiety had worse quality of life scores.35
Differences by gender were also observed in some dimen- sions of
quality of life: women had lower scores in the dimensions vitality,
mental health, and mental component summary, which might be
related to the fact that they had more symptoms of moderate and
severe anxiety than did men. In a previously published Brazilian
work it was found that women living with HIV and patients with
anxiety had worse quality of life scores.35
Differences by gender were also observed in some dimen- sions of
quality of life: women had lower scores in the dimensions vitality,
mental health, and mental component summary, which might be
related to the fact that they had more symptoms of moderate and
severe anxiety than did men. In a previously published Brazilian
work it was found that women living with HIV and patients with
anxiety had worse quality of life scores.35
Differences by gender were also observed in some dimen- sions of
quality of life: women had lower scores in the dimensions vitality,
mental health, and mental component summary, which might be
related to the fact that they had more symptoms of moderate and
severe anxiety than did men. In a previously published Brazilian
work it was found that women living with HIV and patients with
anxiety had worse quality of life scores.35
Differences by gender were also observed in some dimen- sions of
quality of life: women had lower scores in the dimensions vitality,
mental health, and mental component summary, which might be
related to the fact that they had more symptoms of moderate and
severe anxiety than did men. In a previously published Brazilian
work it was found that women living with HIV and patients with
anxiety had worse quality of life scores.35
Differences by gender were also observed in some dimen- sions of
quality of life: women had lower scores in the dimensions vitality,
mental health, and mental component summary, which might be
related to the fact that they had more symptoms of moderate and
severe anxiety than did men. In a previously published Brazilian
work it was found that women living with HIV and patients with
anxiety had worse quality of life scores.35
Differences by gender were also observed in some dimen- sions of
quality of life: women had lower scores in the dimensions vitality,
mental health, and mental component summary, which might be
related to the fact that they had more symptoms of moderate and
severe anxiety than did men. In a previously published Brazilian
work it was found that women living with HIV and patients with
anxiety had worse quality of life scores.35
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
One of the purposes of HAART is to improve the quality of life of
patients, which is confirmed by several studies that have shown an
improvement in quality of life after patients started therapy.36,37 In
this study, however, it was demonstrated that the quality of life of
patients who showed poor adherence was lower in all the
dimensions, and mental health was the most affected.
Furthermore, when compared to another study con- ducted in
Brazil in 2009, with HIV/AIDS patients, regardless of the
adherence level, these results retain lower scores in all
components, including mental component summary.38 On the
other hand, a multicentric study that evaluated the changes during
one year in quality of life of patients on HAART con- cluded that
patients with less than 80% adherence to HAART had lower
quality of life, and patients with continuous adher- ence to
HAART had improvements in quality of life,36 which could
explain in part the results of the present study.
Similarly, several studies established the association of lower
quality of life with depression and anxiety,39,40 some of which
were developed in Brazil.37,41 In this study, presenting clinically
significant anxiety and depression symptomatology was associated
with lower scores in some dimensions of phys- ical health and
mental health.
Similarly, several studies established the association of lower
quality of life with depression and anxiety,39,40 some of which
were developed in Brazil.37,41 In this study, presenting clinically
significant anxiety and depression symptomatology was associated
with lower scores in some dimensions of phys- ical health and
mental health.
with lower scores in some dimensions of phys- ical health and
mental health.
Similarly, several studies established the association of lower
quality of life with depression and anxiety,39,40 some of which
were developed in Brazil.37,41 In this study, presenting clinically
significant anxiety and depression symptomatology was associated
with lower scores in some dimensions of phys- ical health and
mental health.
Similarly, several studies established the association of lower
quality of life with depression and anxiety,39,40 some of which
were developed in Brazil.37,41 In this study, presenting clinically
significant anxiety and depression symptomatology was associated
with lower scores in some dimensions of phys- ical health and
mental health.
In addition, our study showed a significantly higher pro- portion of
women among non-adherent patients, and a strong association
between the presence of moderate or severe levels
In addition, our study showed a significantly higher pro- portion of
women among non-adherent patients, and a strong association
between the presence of moderate or severe levels
In addition, our study showed a significantly higher pro- portion of
women among non-adherent patients, and a strong association
between the presence of moderate or severe levels
In addition, our study showed a significantly higher pro- portion of
women among non-adherent patients, and a strong association
between the presence of moderate or severe levels
307
307
307
308
308
308
309
309
309

Similarly, several studies established the association of lower 310

quality of life with depression and anxiety,39,40 some of which

310
310

were developed in Brazil.37,41 In this study, presenting clinically 311

311
significant anxiety and depression symptomatology was associated 311
with lower scores in some dimensions of phys- ical health and
312
mental health. 312
312
Similarly, several studies established the association of lower
quality of life with depression and anxiety,39,40 some of which 313
313
37,41
were developed in Brazil. In this study, presenting clinically 313

significant anxiety and depression symptomatology was associated 314

314
with lower scores in some dimensions of phys- ical health and 314
mental health. 315
Similarly, several studies established the association of lower 315
315
quality of life with depression and anxiety,39,40 some of which
316
were developed in Brazil.37,41 In this study, presenting clinically 316
316
significant anxiety and depression symptomatology was associated
317
with lower scores in some dimensions of phys- ical health and 317
mental health. 317

Similarly, several studies established the association of lower 318

quality of life with depression and anxiety,39,40 some of which

318
318

were developed in Brazil.37,41 In this study, presenting clinically 319

319
significant anxiety and depression symptomatology was associated
319
333
320 333
320 333
320
334
321 334
321 334
321
335
322 335
322 335
322
336
323 336
323 336
323
337
324 337
324 337
324
338
325 338
325 338
325
339
326 339
326 339
326
340
327 340
327 340
327
341
328 341
328 341
328
342
329 342
329 342
329
343
330 343
330 343
330
344
331 344
331 344
331
345
332 345
332 345
332
Table 4 – Quality of life scores, compared by levels of depression and anxiety of participants with HIV/AIDS, treated in Salvador, Bahia,
2016, who present poor adherence to HAART.
p-Value Minimal and mild
Dimensions Total Moderate and severe
n = 43 Mean (SD)a Moderate and severe
Median Depression, median Anxiety, median Moderate and severe
p-Value
Minimal and mild p-Value
Moderate and severe p-Value
p-Value Minimal and mild p-Value

Physical functioning 40.65 (10.49) 42.4 44.6 39.1 0.008b 40.4 44.6 0.63 Physical Role 38.47 (10.62) 35.0 42.1 27.9 0.002b 42.1 27.9 0.03b Bodily Pain 41.62 (10.73)
42.1 46 37.9 0.12 46 37.9 0.008b General Health 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 0.03b Social
Functioning 36.05 (12.43) 35.4 40.8 30 0.003b 40.8 24.6 0.008b Emotional Role 32.06 (12.70) 23.7 34.3 23.7 0.01b 29 23.7 0.02b Mental Health 34.06 (13.97) 36.8 39
27.7 0.003b 39.1 23.2 0.002b Physical component summary 43.96 (9.64) 42.9 49.3 39.8 0.04b 46.1 41.8 0.42 Mental component summary 33.19 (13.35) 32.9 36.1 26.1
0.002b 36.2 25.8 0.002b

a Reference scores normalized by Short Form-36 mean 50 SD 10. b p < 0.05 for Mann–Whitney U test. c p < 0.01 for Mann–Whitney U test.
 Please cite this article in press as: Betancur MN, et al. Quality of life, anxiety and depression in patients with HIV/AIDS who present poor
BJID 736 1–8 adherence to
antiretroviral therapy: a cross-sectional study in Salvador, Brazil. Braz J Infect Dis. 2017. http://dx.doi.org/10.1016/j.bjid.2017.04.004
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IN PRESS b r a z j i n f e c t d i s . 2 0 1 7;x x x(x x):xxx–xxx 7

of anxiety, depression symptoms, and low scores in quality of life. Similar characteristics were found in a study published in 2016, carried out in
Thailand in patients with HIV/AIDS, which found associations between anxiety in female patients with poor adherence to HAART and
associations between anxiety and depression with low quality of life.34 Therefore, there is a need for further studies to clarify and understand how
gen- der, anxiety, depression, and quality of life might be associated with adherence to HAART.
The role of the psychological component is considered to be fundamental in the management of HIV/AIDS patients. Psychoeducation should be
used to reduce negative beliefs regarding antiretroviral therapy, beyond the initial evaluation and subsequent assessments of anxiety and
depression symp- toms. These points warrant greater attention because they are associated with adherence, the success of the treatment and
ultimately, with the patients’ quality of life. Furthermore, it is pertinent to develop studies related to women’s adherence to HAART, to gather the
necessary information that would allow the implementation of differentiated interventions tailored to women.
Finally, the limitations of this cross-sectional study include difficulties in establishing causal relationships to poor adher- ence, the use of
self-report to assess adherence that could foster under- or overestimating the rates of participants’ adherence, and the small sample size. However,
self-reported adherence is a validated method to evaluate the proper use of antiretroviral drugs, despite some clear limitations.16 The use of a
biological marker (viral load) reduces the effect of inac- curate self-reported adherence levels. In addition, our results clearly pointed out to the
importance of a better evaluation of psychological aspects of women failing antiretroviral therapy due to non-adherence. Strategies to overcome
these barriers are urgently needed.
Conflicts of interest
The authors declare no conflicts of interest.
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Peter E, Kamath R, Andrews T, Hegde BM. Psychosocial 512
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depression symptoms as risk factors for non-adherence

 Please cite this article in press as: Betancur MN, et al. Quality of life, anxiety and depression in patients with HIV/AIDS who present poor
BJID 736 1–8 adherence to
antiretroviral therapy: a cross-sectional study in Salvador, Brazil. Braz J Infect Dis. 2017. http://dx.doi.org/10.1016/j.bjid.2017.04.004