BJID 736 1–8

ARTICLE IN PRESS
braz j infect dis 2 0 1 7;x x x(x x):xxx–xxx

The Brazilian Journal of

INFECTIOUS DISEASES
www.elsevier.com/locate/bjid

1 Original article

2 Quality of life, anxiety and depression in patients

3 with HIV/AIDS who present poor adherence to
4 antiretroviral therapy: a cross-sectional study in
5 Salvador, Brazil

6 Q1 Mónica Narváez Betancur a , Liliane Lins b , Irismar Reis de Oliveira b , Carlos Brites a,b,∗
7
a Universidade Federal da Bahia (UFBA) Programa de Pós-Graduação em Medicina e Saúde, Salvador, BA, Brazil
8
b Universidade Federal da Bahia (UFBA), Faculdade de Medicina, Departamento de Medicina, Salvador, BA, Brazil
9

10 a r t i c l e i n f o a b s t r a c t
11

12 Article history: The introduction of highly active antiretroviral therapy marked a major gain in efficacy of
13 Received 12 December 2016 HIV/AIDS treatment and a reduction in morbidity and mortality of the infected patients.
14 Accepted 17 April 2017 However, high levels of adherence are required to obtain virologic suppression. In Brazil,
15 Available online xxx the policy of free and universal access to antiretroviral therapy has been in place since 1996,
16 although there are reports of poor adherence.
17 Keywords: Objective: To define the clinical, demographic and psychological characteristics, and quality
18 Highly active antiretroviral therapy of life of patients with HIV/AIDS who present poor adherence to highly active antiretroviral
19 HIV/AIDS therapy.
20 Adherence Methods: This was a cross-sectional study. To be included in the study patients had to be 18
21 Nonadherence through 65 years old, diagnosed with HIV/AIDS, having the two previous viral loads above
22 Anxiety 500 copies, a surrogate for poor adherence to antiretrovirals. The following instruments were
23 Depression applied to all eligible patients: the sociodemographic questionnaire “Adherence Follow-up
24 Quality of life 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/).

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
 BJID 736 1–8
ARTICLE IN 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

25 depression symptoms should be done throughout therapy as both psycological conditions

26 are associated with patient adherence, success of treatment, and ultimately with patients’
27 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/
28 licenses/by-nc-nd/4.0/).

Introduction Materials and methods

29 The introduction of highly active antiretroviral therapy Study setting 78

30 (HAART) in the 1990s marked a major gain in HIV/AIDS treat-

This study was conducted at the Prof. Edgard Santos Univer- 79
31 ment efficacy, and a reduction in morbidity, mortality, and
32 quality of life of these patients. In Brazil, the policy of free and sity Hospital (HUPES), Salvador, Bahia, Brazil, a reference cen- 80

ter that provides health care services at the outpatient clinic

universal access to antiretroviral therapy1 has been in place
81
33

34 since 1996. Currently, the recommendation is for early onset or by hospitalization, for patients with HIV/AIDS diagnosis. 82

35 of HAART, due to the benefits for people living with HIV/AIDS

36 as well as for viremia control.2,3 Study design and population 83

37 However, in order for HAART to be successful, adherence is

This study was a cross-sectional study carried out between 84
38 crucial and is strictly associated with virologic suppression.4,5
February and May of 2016. Patients with HIV, on antiretro- 85
39 Therefore, the efficacy of HAART depends on maintaining high
viral therapy for at least one year, aged between 18 and 65 86
40 rates of treatment adherence, considered in most of the sci-
years, receiving care at the AIDS outpatient clinics, having the 87
41 entific literature as adherence equal to or greater than 95% of
last two viral loads above 500 copies, and who could read and 88
42 the prescribed dosages.6 Although the more potent drug regi-
write were invited to participate. Patients who presented neu- 89
43 mens currently used allow for moderate adherence levels, no
rocognitive impairment or psychotic disturbances that could 90
44 regimen allows for a partial adherence.7
compromise their understanding of the study were excluded. 91
45 Low levels of adherence increase disease progression as
During the study period, 1395 patients with an HIV/AIDS 92
46 well as viral resistance, and limit the therapeutic options.
diagnosis looked for care at the HUPES outpatient clinic; of 93
47 In Brazil, between 1999 and 2008, there were reports of
these, 898 were male and 497 were female, and had their 94
48 poor adherence to HAART, varying between 23.3% and
medical records were checked for the eligibility criteria con- 95
49 36.9%.8–10
sidered. A total of 1331 patients did not meet the inclusion 96
50 Adherence is a complex dynamic and multifactorial
criteria thus leaving 64 patients to be studied. However, 17 97
51 process that encompasses physical, psychological, social, cul-
(26%) patients refused to participate remaining 47 (73.4%) to 98
52 tural, and behavioral aspects.2 Therefore, there are diverse
be evaluated (Fig. 1). 99
53 challenges faced by people living with HIV/AIDS associated
54 with the difficulties in maintaining high and prolonged levels
55 of therapeutic adherence. In previous studies on the factors Assessments
56 associated with poor adherence, the following were empha-
57 sized: depression, anxiety, low social support, complexity of Sociodemographic characteristics 100
58 therapeutic regimen, relationship with medical personnel,
59 low level of schooling, side effects, negative beliefs about the A structured questionnaire was developed for the study aimed 101

60 treatment, stigma, and alcohol/substance abuse.2,11 at obtaining the participants’ sociodemographic information: 102

61 In short, the predictive factors of nonadherence may gender, age, ethnicity, marital status, sexual orientation, edu- 103

62 be grouped as follows: patient characteristics, the pre- cation, occupation, and types of support. Furthermore, they 104

63 scribed treatment regimen, the characteristics of the disease, were asked questions related to their habits and health condi- 105

64 doctor-patient relationship, and the location of medical care tions, such as year of diagnosis and when they began HAART, 106

65 delivery.12,13 Thus, the initial challenge for the managers other chronic illnesses, alcohol consumption, use of psychoac- 107

66 of national policies and health care services specialized in tive drugs, and medical assistance. Their medical records were 108

67 HIV/AIDS is to understand how all these factors influence reviewed to obtain information on the most recent viral load 109

68 patient adherence, in order to establish effective actions, and the CD4+ lymphocyte count. 110

69 adjusted to the population characteristics. Furthermore, there

70 are few studies in Brazil that evaluate the factors associated Adherence 111

71 with low adherence and the quality of life of patients undergo-

72 ing HAART.14,15 Therefore, the main objective of this study was Two questionnaires were used to measure adherence: (1) 112

73 to define the clinical-demographic and psychological charac- “Adherence Follow-up Questionnaire” from the Aids Clinical 113

74 teristics as well as quality of life and beliefs about HAART of Trial Groups (ACTG),16 translated to Portuguese17 to assess 114

75 the patients who present poor adherence to HAART, and eval- self-reported adherence in the previous four days, use of pills 115

76 uate the relation of some of these characteristics to adherence by dosage and reasons for not taking the drugs; and (2) a 116

77 and quality of life. questionnaire on knowledge and beliefs related to AIDS and 117

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
 BJID 736 1–8
ARTICLE 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 3

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.

118 to HAART, developed by the same group and translated to Por- questionnaire has 36 questions that measure quality of life 144

119 tuguese by a previous study.18 related to health in eight dimensions: Physical Functioning, 145

120 Adherence was calculated as the number of doses that were Physical Role, Bodily Pain, General Health, Vitality, Social Func- 146

121 effectively taken divided by the number of prescribed doses in tioning, Emotional Role, and Mental Health. Furthermore, the 147

122 the previous four days. Participants with adherence greater or questionnaire allows for evaluations of the physical compo- 148

123 equal to 95% were considered as being adherent. nent summary as well as the mental component summary. 149

124 Depression Statistical analysis 150

125 The Beck Depression Inventory II (BDI-II) in the Portuguese The descriptive analyses of the qualitative variables were 151

126 version19,20 was used to measure depression symptoms. The presented in absolute and relative frequencies. Continuous 152

127 BDI-II is a self-reported scale with 21 items, each one with four variables with normal distribution (age) were presented as 153

128 choices of answer that imply increasing levels of depression mean and standard deviation. Continuous variables without 154

129 severity. The total score is the sum of the individual scores normal distribution (years since diagnosis, years of treatment, 155

130 of the items and provides the classification of the intensity of number of pills, viral load, and CD4+ lymphocyte count) were 156

131 depression as minimal, mild, moderate, or severe. expressed as median, minimum and maximum. Scores of 157

quality of life were compared between genders and between 158

132 Anxiety those who had or had not used antiretroviral drugs in the last 159

month by the Mann–Whitney nonparametric test. 160

133 The Beck Anxiety Inventory (BAI), Portuguese version,20 com- Furthermore, the depression and anxiety variables were 161

134 prising 21 items or anxiety symptom affirmations that are categorized in dichotomous variables (minimal and mild, 162

135 evaluated by the subject on a scale of four points related to and moderate and severe), with moderate and severe 163

136 the levels of increasing severity of each symptom, was used to being considered as the presence of clinically significant 164

137 assess the anxiety symptoms of the patients. The total score symptomatology.19,22 Comparisons among dimensions of 165

138 is the sum of the individual scores of the items and provides quality of life were carried out using the Mann–Whitney 166

139 the classification of the intensity level of anxiety as minimal, nonparametric test. In the same way, Pearson’s chi-squared 167

140 mild, moderate, or severe. test was used to evaluate whether the intensity of anxiety 168

and depression symptoms were associated with the partic- 169

141 Quality of life ipants’ gender, and also whether the most relevant reason 170

reported by the participants for stopping HAART was asso- 171

142 To estimate quality of life, the 36-item Short Form Health ciated with the intensity of depression symptoms. A p-value 172

143 Survey (SF-36), Portuguese version21 was chosen. This less than 0.05 was considered statistically significant. The 173

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
 BJID 736 1–8
ARTICLE IN PRESS
4 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

174 Statistical Package for the Social Sciences (SPSS) version 20.0 female, mean age 41.9 years (±10.5), and 46.8% self-reported as 183

175 for Windows was used. being of black ethnicity. Regarding marital status, 46.8% were 184

single and 40.4% married; the majority (89.4%) was heterosex- 185

176 Ethical considerations ual. Only 53.2% had an individual income, and of these 23.4% 186

reported the income originated from disability/retirement 187

177 The present study was approved by the Research Ethics Com- insurance payment related to illness. In the realm of social 188
178 mittee of the School of Medicine of the Federal University of support, 91.6% of the participants reported that the family was 189
179 Bahia, in August of 2015 (case number 1.154.393). All partici- aware of the HIV diagnosis, and 83% reported having family 190
180 pants signed a written consent form. support. Alcohol consumption in the last three months were 191

admitted by 51.1%, with 21.3% having consumed at least once 192

Results a week, and 14.9% had heavy alcohol consumption, defined 193

as five or more doses more than once a week. Only 6.4% (all 194

181 The sociodemographic characteristics of the participants are males) reported use of other psychoactive substances in addi- 195

182 presented in Table 1. Of the 47 participants, 70.2% were tion to heavy alcohol consumption. 196

The clinical and psychological characteristics are listed 197

in Table 2. The mean number of years since diagnosis was 198

Table 1 – Sociodemographic characteristics of the
13.5 (minimum 2 and maximum 28), and the average number 199
participants with HIV/AIDS who present poor adherence
of years on treatment was 13 (minimum 1 and maximum 200
to HAART, in Salvador, Bahia, 2016.
20); at the time of evaluation the mean TCD4+ lymphocytes 201
Variables Total n = 47 (%)
was 366 cells/␮L (minimum 1 and maximum 970), and 80% 202

Female sex 33 (70.2) of the participants presented a viral load between 400 and 203

Age (years) (mean, Ds) 41.9 (±10.5) 100,000 copies. Moreover, among the participants who had 204

Ethnicity other chronic diseases requiring medication, depression was 205

Black 22 (46.8) the most common, with 31.2%. It is relevant because 59.5% 206

Racially mixed 13 (27.7) of all patients presented moderate to severe symptoms of 207
White 10 (21.3) depression, and 44.7% presented anxiety symptoms. That 208
Indigenous 2 (4.3)
means that only a minority were on treatment for such 209

Education problems. An association was also found between stopping 210

Elementary school, complete/incomplete 22 (46.8) HAART due to feeling depressed and moderate and severe 211
High school, complete/incomplete 25 (53.2)

Marital status
Single 22 (46.8)
Married/living with partner 19 (40.4) Table 2 – Clinical and psychological characteristics of
Divorced/widowed 6 (12.7) participants with HIV/AIDS who present poor adherence
to HAART, treated in Salvador, Bahia, 2016.
Sexual orientation
Heterosexual 42 (89.4) Variables Total n = 47 (%)
Homosexual 4 (8.5)
Years since diagnosis (n = 45) (Md; min-max) 13.5 (2–28)
Bisexual 1 (2.1)
Years of HAART (n = 40) (Md; min-max) 13 (1–20)
Individual income Number of pills per day (Md; min-max) 3 (1–9)
Has individual income 25 (53.2) Self-reported Adherence ≥ 95% 24 (51.1)
Has no individual income 22 (46.8) CD4+ (Md; min-max) 366 (1–970)
Early retirement due to illness 11 (23.4)
Viral load (n = 45)
Family support 400–100,000 36 (80)
Support 39 (83) 100,000 9 (20)
Reject 4 (8.6)
Other chronic diseases with medication 16 (34.0)
No one knows the diagnosis 4 (8.6)
Depression with medication 5 (10.6)
Type of supporta
Depressiona
Spiritual 23 (48.9)
Minimal 9 (19.1)
Emotional 7 (14.8)
Mild 10 (21.3)
Therapeutic 5 (10.6)
Moderate 19 (40.4)
Financial 12 (25.5)
Severe 9 (19.1)
No type of support 8 (17)
Anxietyb
Alcohol
Minimal 11 (23.4)
Consumed alcohol in the last three months 24 (51.1)
Mild 15 (31.9)
Frequent alcohol consumption (at least 10 (21.3)
Moderate 13 (27.7)
once a week)
Severe 8 (17.0)
Heavy alcohol consumption 7 (14.9)
a
Psychoactive substance consumption 3 (6.4) Beck Depression 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
 BJID 736 1–8
ARTICLE 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 5

Feel well 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 44,7%

0% 10% 20% 30% 40% 50%

Fig. 2 – Reasons for stopping therapy among HIV/AIDS patients who present poor adherence to HAART, in Salvador, Brazil.

212 intensity of depression symptoms (p = 0.02). When evaluating ipants presented lower than expected (by scale’s reference 234

213 the association of gender with anxiety and depression, an values) mean scores in all the dimensions (Table 4), with 235

214 association was observed between the female sex and mod- the dimensions of the mental component having the lowest 236

215 erate and severe anxiety symptoms (p = 0.006) but there was score. Moreover, when comparing gender, women had lower 237

216 no association between gender and symptoms of depression scores in the dimensions of vitality (males: 47.9, females: 37.2; 238

217 (p = 0.13). p = 0.03), mental health (males: 40.2, females: 32.3; p = 0.008) 239

218 Regarding adherence, although 51.1% of the participants and mental component summary (males: 39.5, females: 31.7; 240

219 presented adherence equal to or greater than 95% in the previ- p = 0.014). Furthermore, the patients who missed doses of 241

220 ous four days, 57.4% did not take some of the medication in the antiretrovirals in the previous month had lower scores in 242

221 previous week, and 74.5% in the month prior. The most rele- the dimensions of general health (yes 39.2, not 50.9; p = 0.01) 243

222 vant reason for not taking HAART (Fig. 2) was being depressed, and bodily pain (yes 41.8, not 50.8; p = 0.01). When comparing 244

223 with 46.8%, and other reasons were being away from home intensity of anxiety and depression symptoms (Table 4), the 245

224 44.7%; forgetfulness; avoiding undesired side effects, and tak- patients who had moderate and severe symptoms of depres- 246

225 ing the pills at specific times, with 38.3% each. On the other sion or anxiety also had lower scores in all dimensions except 247

226 hand, even though 89.4% of the participants acknowledged depression with bodily pain (p = 0.12) and anxiety with physi- 248

227 that taking HAART helps one remain healthy for a longer time, cal functioning (p = 0.63), general health (p = 0.35) and physical 249

228 they also showed some negative beliefs related to the treat- component summary (p = 0.42). 250

229 ment: 89.4% believed that the side effects were intense, 74.4%
230 thought that taking HAART meant you had AIDS, and 72.3%
231 had the belief that HAART was toxic (Table 3).
Discussion
232 When evaluating quality of life related to health from a
233 multidimensional approach, it was observed that the partic-
The aim of this study was to identify the relevant character- 251

istics that might have been associated with non-adherence to 252

treatment, in a group of patients who presented poor adher- 253

Table 3 – Beliefs about HAART of participants with ence to HAART. During the time period of the study, 898 (64.4%) 254

HIV/AIDS, treated in Salvador, Bahia, 2016, who present men and 497 (35.6%) women were treated at the HUPES out- 255
poor adherence to antiretroviral therapy. patient clinic. It is noteworthy that more women (33 subjects, 256

Variables Total n = 47 (%) 70% of sample) showed poor adherence to HAART. This result 257

is consistent with a study developed in Belo Horizonte, MG, 258

Undergoing HAART is a good idea 37 (78.7)
that confirmed poorer adherence among women.23 Likewise, 259
even if you don’t have symptoms
HAART has demonstrated its efficacy 32 (68.0) another multicentric study developed by the AIDS Clinical Tri- 260

By undergoing HAART a person will be 42 (89.4) als Group in the United States, Puerto Rico and Italy24 reported 261

healthy for longer women as having a greater risk of virologic failure due to 262
Side effects are intense for most 42 (89.4) poor adherence. Nevertheless, there are other recent studies 263
people that did not find a relationship between gender and levels of 264
Undergoing HAART means you have 35 (74.4)
adherence.25,26 Moreover, a systematic review on differences 265
AIDS
HAART is toxic for most people 34 (72.3)
of adherence according to gender found a marginally signifi- 266

cant difference of lower adherence in women.27 267

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
 BJID 736 1–8
ARTICLE IN PRESS
6 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

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.
Dimensions Total Median Depression, median Anxiety, median
n = 43 Mean (SD)a
Minimal Moderate p-Value Minimal Moderate p-Value
and mild and severe and mild and severe

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.

268 This study also investigated the participants’ beliefs about population, our results were expected, and reinforces the 307

269 HAART and the reasons for not using the treatment. Although importance of anxiety in the adherence process. A relation- 308

270 they admitted that HAART was effective and helped one to ship with the intensity of anxiety symptoms and female 309

271 remain healthy for a longer time, negative ideas related to gender was also observed, which is consistent with a study 310

272 side effects, toxicity, and the concept that undergoing HAART published in 2016.34 This also reinforces the importance of 311

273 meant one had AIDS were also presented. A review article on finding a high proportion of women in our study. 312

274 adherence and HAART demonstrated that the patient’s belief Differences by gender were also observed in some dimen- 313

275 system about the nature of the illness, its treatment, and the sions of quality of life: women had lower scores in the 314

276 fears regarding side effects may be important obstacles to dimensions vitality, mental health, and mental component 315

277 adherence.6 It is noteworthy that avoiding undesirable side summary, which might be related to the fact that they had 316

278 effects was also one of the relevant reasons reported by 38.3% more symptoms of moderate and severe anxiety than did men. 317

279 of the participants for stopping HAART, a finding that is near In a previously published Brazilian work it was found that 318

280 the 33.3% found in another Brazilian study.28 women living with HIV and patients with anxiety had worse 319

281 High prevalence of depression and symptoms of depres- quality of life scores.35 320

282 sion have been widely demonstrated in the literature in One of the purposes of HAART is to improve the quality of 321

283 patients with HIV/AIDS. Prevalence studies reported a 28.1% in life of patients, which is confirmed by several studies that have 322

284 France,29 25.6% in the United States,30 and 32% in Brazil.31 Sev- shown an improvement in quality of life after patients started 323

285 eral studies mention depression as one of the most important therapy.36,37 In this study, however, it was demonstrated that 324

286 barriers to adhering to HAART.6,32 In this study, we found that the quality of life of patients who showed poor adherence was 325

287 the reason for stopping HAART because of feeling depressed lower in all the dimensions, and mental health was the most 326

288 was associated with moderate and severe levels of depres- affected. Furthermore, when compared to another study con- 327

289 sion symptoms. This finding is even more relevant when ducted in Brazil in 2009, with HIV/AIDS patients, regardless 328

290 considering that feeling depressed was the greatest reason of the adherence level, these results retain lower scores in all 329

291 reported by the participants for stopping HAART and that most components, including mental component summary.38 On the 330

292 (59.5%) of them presented clinically significant symptoms of other hand, a multicentric study that evaluated the changes 331

293 depression.19,22 during one year in quality of life of patients on HAART con- 332

294 The percentage of participants who presented depressive cluded that patients with less than 80% adherence to HAART 333

295 symptoms between moderate and severe (59.5%) was signif- had lower quality of life, and patients with continuous adher- 334

296 icantly higher than those from other Brazilian studies (18% ence to HAART had improvements in quality of life,36 which 335

297 and 21.5%),31,33 that evaluated patients with HIV who did not could explain in part the results of the present study. 336

298 necessarily have adherence issues as in this present study. Similarly, several studies established the association of 337

299 In addition, only 10.6% had prescriptions of antidepressive lower quality of life with depression and anxiety,39,40 some of 338

300 drugs. Other studies mention that between 50% and 60% of which were developed in Brazil.37,41 In this study, presenting 339

301 the patients with depression are undiagnosed.31 clinically significant anxiety and depression symptomatology 340

302 The rates of moderate and severe symptoms of anxiety was associated with lower scores in some dimensions of phys- 341

303 were higher in this study (44.7%) than in another previous ical health and mental health. 342

304 study in Brazil (35.8%), that detected symptoms of severe anx- In addition, our study showed a significantly higher pro- 343

305 iety (12.6%) as an important predictor for non-adherence to portion of women among non-adherent patients, and a strong 344

306 HAART.33 Since our work was focused on a non-adherent association between the presence of moderate or severe levels 345

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
 BJID 736 1–8
ARTICLE 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

346 of anxiety, depression symptoms, and low scores in quality of 6. Chesney M. Adherence to HAART regimens. AIDS Patient Care 402

347 life. Similar characteristics were found in a study published in STDS. 2003;17:169–77. 403

348 2016, carried out in Thailand in patients with HIV/AIDS, which 7. Peltzer K, Ramlagan S, Jones D, Weiss SM, Fomundam H, 404

349 found associations between anxiety in female patients with Chanetsa L. Efficacy of a lay health worker led group 405
antiretroviral medication adherence training among 406
350 poor adherence to HAART and associations between anxiety
non-adherent HIV-positive patients in KwaZulu-Natal, South 407
351 and depression with low quality of life.34 Therefore, there is Africa: results from a randomized trial. SAHARA J. 408
352 a need for further studies to clarify and understand how gen- 2012;9:218–26. 409
353 der, anxiety, depression, and quality of life might be associated 8. de Carvalho CV, Merchan-Hamann E, Matsushita R. 410

354 with adherence to HAART. [Determinants of antiretroviral treatment adherence in 411

355 The role of the psychological component is considered to Brasilia, Federal District: a case-control study]. Rev Soc Bras 412
Med Trop. 2007;40:555–65. 413
356 be fundamental in the management of HIV/AIDS patients.
9. Bonolo PF, Machado CJ, Cesar CC, Ceccato M, Guimarães MD. 414
357 Psychoeducation should be used to reduce negative beliefs
Vulnerability and non-adherence to antiretroviral therapy 415
358 regarding antiretroviral therapy, beyond the initial evaluation among HIV patients, Minas Gerais State, Brazil. Cad Saude 416
359 and subsequent assessments of anxiety and depression symp- Publica. 2008;24:2603–13. 417

360 toms. These points warrant greater attention because they are 10. Brigido LF, Rodrigues R, Casseb J, et al. Impact of adherence to 418

361 associated with adherence, the success of the treatment and antiretroviral therapy in HIV-1-infected patients at a 419

362 ultimately, with the patients’ quality of life. Furthermore, it is university public service in Brazil. AIDS Patient Care STDS. 420
2001;15:587–93. 421
363 pertinent to develop studies related to women’s adherence to
11. Remien RH, Bastos FI, Jnr VT, et al. Adherence to 422
364 HAART, to gather the necessary information that would allow antiretroviral therapy in a context of universal access, in Rio 423
365 the implementation of differentiated interventions tailored to de Janeiro, Brazil. AIDS Care. 2007;19:740–8. 424
366 women. 12. Ickovics JR, Meade CS. Adherence to HAART among patients 425

367 Finally, the limitations of this cross-sectional study include with HIV: breakthroughs and barriers. AIDS Care. 426

368 difficulties in establishing causal relationships to poor adher- 2002;14:309–18. 427

369 ence, the use of self-report to assess adherence that could 13. Fogarty L, Roter D, Larson S, Burke J, Gillespie J, Levy R. Patient 428
adherence to HIV medication regimens: a review of published 429
370 foster under- or overestimating the rates of participants’
and abstract reports. Patient Educ Couns. 2002;46:93–108. 430
371 adherence, and the small sample size. However, self-reported 14. Silva JA, Dourado I, Brito AM, Silva CA. Factors associated 431
372 adherence is a validated method to evaluate the proper use of with non-adherence to antiretroviral therapy in adults with 432
373 antiretroviral drugs, despite some clear limitations.16 The use AIDS in the first six months of treatment in Salvador, Bahia 433

374 of a biological marker (viral load) reduces the effect of inac- State, Brazil. Cad Saude Publica. 2015;31:1188–98. 434

375 curate self-reported adherence levels. In addition, our results 15. Zubaran C, Medeiros G, Foresti K, May W, Michelim L, Madi 435
JM. Quality of life and adherence to antiretroviral therapy in 436
376 clearly pointed out to the importance of a better evaluation of
Southern Brazil. AIDS Care. 2014;26:619–25. 437
377 psychological aspects of women failing antiretroviral therapy
16. ACTG, Adherence follow up questionnaire. Available from: 438
378 due to non-adherence. Strategies to overcome these barriers https://www.frontierscience.org/apps/cfmx/apps/common/ 439
379 are urgently needed. QOLAdherenceForms/resources/actg/forms/english/ql0702 440
.pdf [accessed 5.5.16]. 441
17. Ricci G, Netto EM, Luz E, Rodamilans C, Brites C. Adherence to 442

Conflicts of interest antiretroviral therapy of Brazilian HIV-infected children and 443

their caregivers. Braz J Infect Dis. 2016;20:429–36. 444
18. Sampaio-Sa M, Page-Shafer K, Bangsberg DR, et al. 100% 445
380 The authors declare no conflicts of interest.
adherence study: educational workshops vs. video sessions to 446

381 improve adherence among ART-naive patients in Salvador, 447

references Brazil. AIDS Behav. 2008;12 4 Suppl:S54–62. 448

382 19. Gomes-Oliveira MH, Gorenstein C, Lotufo Neto F, Andrade LH, 449
Wang YP. Validation of the Brazilian Portuguese version of the 450

◦
Beck Depression Inventory-II in a community sample. Rev 451
383 1. BRASIL. Congresso Nacional. Lei n 9.313, 13 de novembro de Bras Psiquiatr. 2012;34:389–94. 452
384 1996. Dispõe sobre a distribuição gratuita de medicamentos 20. Cunha JA. Manual da versão em português das Escalas Beck. 453
385 aos portadores do HIV e doentes de AIDS. Diário Oficial [da São Paulo: Casa do Psicólogo; 2001. 454
386 República Federativa do Brasil], Brasília, DF. (14 de nov 1996). 21. Ciconelli RM, Ferraz MB, Santos W, Meinão I, Quaresma MR. 455
387 2. Ministerio da Saúde. Secretaria de Vigilância em Saúde. Tradução para a língua portuguesa e validação do 456
388 Protocolo clínico e diretrizes terapêuticas para manejo da questionário genérico de avaliação de qualidade 457
389 infecção pelo HIV em adultos. Brasilia: Departamento de DTS, de vida SF-36 (Brasil SF-36). Rev Bras Reumatol. 458
390 Aids e Hepatites Virais; 2013. p. 216. 1999;39:143–50. 459
391 3. Günthard HF, Saag MS, Benson CA, et al. Antiretroviral drugs 22. Dozois DJA, Dobson KS, Ahnberg JL. A psychometric 460
392 for treatment and prevention of HIV infection in adults: 2016 evaluation of the Beck Depression Inventory-II. Psychol 461
393 recommendations of the international antiviral society–USA Assess. 1998;10:83–9. 462
394 panel. JAMA. 2016;316:191–210. 23. Bonolo PF, Cesar CC, Acurcio FA, et al. Non-adherence among 463
395 4. Bangsberg DR, Perry S, Charlebois ED, et al. Non-adherence to patients initiating antiretroviral therapy: a challenge for 464
396 highly active antiretroviral therapy predicts progression to health professionals in Brazil. AIDS. 2005;19 Suppl 465
397 AIDS. AIDS. 2001;15:1181–3. 4:S5–13. 466
398 5. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral 24. Collier AC, Ribaudo H, Mukherjee AL, Feinberg J, Fischl MA, 467
399 treatment of adult HIV infection: 2012 recommendations of Chesney M. A randomized study of serial telephone call 468
400 the international antiviral society–USA panel. JAMA. support to increase adherence and there by improve virologic 469
401 2012;308:387–402.

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
 BJID 736 1–8
ARTICLE IN PRESS
8 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

470 outcome in persons initiating antiretroviral therapy. J Infect to antiretroviral therapy in Brazil. AIDS Behav. 2010;14: 503
471 Dis. 2005;192:1398–406. 289–99. 504
472 25. McCoy K, Waldrop-Valverde D, Balderson BH, Mahoney C, 34. Prasithsirikul W, Chongthawonsatid S, Ohata PJ, et al. 505
473 Catz S. Correlates of antiretroviral therapy adherence among Depression and anxiety were low amongst virally suppressed, 506
474 HIV-infected older adults. J Int Assoc Provid AIDS Care. long-term treated HIV-infected individuals enrolled in a 507
475 2016;15:248–55. public sector antiretroviral program in Thailand. AIDS Care. 508
476 26. Beer L, Mattson CL, Bradley H, Skarbinski J. Understanding 2016:1–7. 509
477 cross-sectional racial, ethnic, and gender disparities in 35. Passos SM, Souza LD. An evaluation of quality of life and its 510
478 antiretroviral use and viral suppression among HIV patients determinants among people living with HIV/AIDS from 511
479 in the United States. Medicine (Baltimore). 2016;95:e3171. Southern Brazil. Cad Saude Publica. 2015;31:800–14. 512
480 27. Ortego C, Huedo-Medina TB, Santos P, et al. Sex differences in 36. Mannheimer SB, Matts J, Telzak E, et al. Quality of life in 513
481 adherence to highly active antiretroviral therapy: a HIV-infected individuals receiving antiretroviral therapy is 514
482 meta-analysis. AIDS Care. 2012;24:1519–34. related to adherence. AIDS Care. 2005;17:10–22. 515
483 28. Guimarães MD, Rocha GM, Campos LN, et al. Difficulties 37. Campos LN, Cesar CC, Guimarães MD. Quality of life among 516
484 reported by HIV-infected patients using antiretroviral therapy HIV-infected patients in Brazil after initiation of treatment. 517
485 in Brazil. Clinics (Sao Paulo). 2008;63:165–72. Clinics (Sao Paulo). 2009;64:867–75. 518
486 29. Feuillet P, Lert F, Tron L, Aubriere C, Spire B, Dray-Spira R. 38. Soarez PC, Castelo A, Abrão P, Holmes WC, Ciconelli RM. 519
487 Prevalence of and factors associated with depression among [Brazilian-Portuguese translation and validation of the 520
488 people living with HIV in France. HIV Med. 2016. HIV/AIDS-Targeted Quality of Life Instrument]. Rev Panam 521
489 30. Do AN, Rosenberg ES, Sullivan PS, et al. Excess burden of Salud Publica. 2009;25:69–76. 522
490 depression among HIV-infected persons receiving medical 39. Ezeamama AE, Woolfork MN, Guwatudde D, et al. Depressive 523
491 care in the United States: data from the medical monitoring and anxiety symptoms predict sustained quality of life 524
492 project and the behavioral risk factor surveillance system. deficits in HIV-positive Ugandan adults despite antiretroviral 525
493 PLoS One. 2014;9:e92842. therapy: a prospective cohort study. Medicine (Baltimore). 526
494 31. Silveira MP, Guttier MC, Pinheiro CA, Pereira TV, Cruzeiro AL, 2016;95:e2525. 527
495 Moreira LB. Depressive symptoms in HIV-infected patients 40. Peter E, Kamath R, Andrews T, Hegde BM. Psychosocial 528
496 treated with highly active antiretroviral therapy. Rev Bras determinants of health-related quality of life of people living 529
497 Psiquiatr. 2012;34:162–7. with HIV/AIDS on antiretroviral therapy at Udupi District, 530
498 32. Krumme AA, Kaigamba F, Binagwaho A, Murray MB, Rich ML, Southern India. Int J Prev Med. 2014;5:203–9. 531
499 Franke MF. Depression, adherence and attrition from care in 41. Tostes MA, Chalub M, Botega NJ. The quality of life of 532
500 HIV-infected adults receiving antiretroviral therapy. J HIV-infected women is associated with psychiatric morbidity. 533
501 Epidemiol Commun Health. 2015;69:284–9. AIDS Care. 2004;16:177–86. 534
502 33. Campos LN, Guimarães MD, Remien RH. Anxiety and
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