Adherence to Antiretroviral Therapy in People Living with HIV/AIDS: A Cross-Sectional Study

Abstract

Adherence to antiretroviral therapy (ART) is essential to suppress HIV replication, preserve immune competence, and ensure quality of life for people living with HIV/AIDS. This is a cross-sectional study to assess adherence to ART in HIV-infected adults and its associated factors in São Carlos, SP, Brazil, from June 2018 to January 2019. Standardized interviews were conducted covering demographic, clinical, and laboratory characteristics and instruments to assess compliance to treatment (CEAT-VIH), HIV/AIDS-targeted quality of life (HAT-QoL), and self-efficacy expectations of adherence (SEA-ART). Each variable was analyzed for association with adherence to ART, by refilling at least 90% of the prescribed doses in the 6 months before the interview date. The study consisted of 220 participants, with a mean age of 43 years, 60.5% male, and 24.5% men who have sex with men. Previous consumption of alcohol or illicit drugs was reported by 44.1% of participants and current or previous smoking by 34.1%. The most common regimen was two nucleoside reverse transcriptase inhibitors combined with one non-nucleoside reverse transcriptase inhibitor (37.3%). The adherence to ART was 62%, and the factors associated with it were living alone [adjusted odds ratio (aOR) 2.79], not having an active sexual life (aOR 0.43), not being a smoker (aOR 0.36), having a CD4 count ≥350 cells/mm³ (aOR 2.50), and having a SEA-ART Score >100 (aOR 1.94). The fear of disclosing HIV status could make adherence to treatment difficult. This could be the reason that living alone and not having an active sexual life have been associated with better adherence. Encouraging healthy lifestyle habits and promoting self-efficacy tools can also improve adherence.

Introduction

AIDS remains a public health problem, with ∼37.7 million people living with HIV/AIDS (PLWHA) worldwide, of which 27.5 million have access to antiretroviral therapy (ART). There were 1.5 million new infections and 680,000 deaths from AIDS-related causes in 2020.¹

Despite the initial success of the National STI/AIDS Program with the control of new cases of HIV infection, Brazil experienced a resurgence of the epidemic in the 2000s with a peak in 2010 due to the population's greater access to serological diagnosis and a real increase in the incidence of new cases, particularly in men who have sex with men (MSM). This rise in incidence was probably due to increased risk behavior, the existence of undiagnosed individuals, and low ART adherence in the diagnosed population.²

ART adherence is recognized as a dynamic, complex, multi-factorial, comprehensive, and difficult-to-measure process. The most common methods used to monitor adherence to ART are self-report medication adherence measures, pharmacy refill data, medication event monitoring systems (MEMS), and therapeutic serum concentration drug monitoring.^3,4

Several factors are associated with the adherence of HIV-infected patients to ART, which were grouped into the following categories: individual variables, treatment characteristics, characteristics of HIV infection/AIDS, relationship with health services, and social support. It recommends that services characterize the user profile, systematize adherence measures, and regionally assess factors associated with adherence, for early detection of nonadherence to antiretrovirals and establishment of effective intervention plans.^5,6

Low adherence to or abandonment of ART seems to result in the failure of basic treatment regimens, which may lead to the need for therapeutic regimens considered to be salvage, which are more complex and generally require a larger number of pills. Low adherence is considered a threat at the individual and collective levels as it compromises the effectiveness of therapy and favors the spread of viruses resistant to available drugs.⁷

Knowing the adherence to antiretroviral and identifying possible protective factors in a specific population can provide important data for the management of actions in HIV infection prevention and control programs. This study aimed to assess adherence to ART and its associated factors in PLWHA in a mid-sized inner city of São Paulo, Brazil.

Methods

This cross-sectional observational study was carried out in a specialized outpatient service, the Centro de Atendimento de Infecções Crônicas (CAIC) de São Carlos, São Paulo, Brazil, which serves six municipalities in the central-east region of São Paulo State. The eligible participants were HIV-infected adults (18 years of age or older) with ART for at least 3 months, and with cognitive capacity enough to ensure an adequate informed consent. Pregnant women were excluded. The Investigational Review Board of the Universidade Federal de São Carlos approved the research project, CAAE: 88170518.7.0000.5504.

A medical record review carried out in 2018 was used to estimate the number of PLWHA under follow-up at the center. A total of 1446 individuals were registered, 315 abandoned the treatment, 31 died, and 234 were transferred.⁸ Therefore, there were 866 people in follow-up. For sample calculation purposes, treatment adherence rate was estimated between 70% and 75%.^6,7,9

Sample size was calculated using the Epi Info 7™ public domain software (Centers for Disease Control and Prevention, Atlanta, GA) for statistical analysis, considering a total population of 866 PLWHA, a 75% expected adherence to antiretrovirals, a 5% margin of error, and a 95% significance level. Thus, the sample size was 216 individuals. Participants were chosen by random sampling stratified by sex and age.

According to UNAIDS reports, in 2017, there were 860,000 PLWHA in Brazil, with 69% between 25 and 49 years of age, 10% between 15 and 24 years of age, and 20% older than 49 years, with a male-female ratio of 11:6.¹⁰ Sixteen sample strata classified by sex (M/F) and age group (18–24 years, 25–29 years, 30–34 years, 35–39 years, 40–44 years, 45–49 years, 50–54 years, and 55 or more years) were created. Each stratum should have at least ten individuals. The aim was to ensure that each sex-age stratum was properly represented, with a proportion similar to that observed in the overall HIV population.

The study sample consisted of 220 participants. Data collection was carried out from June 2018 to January 2019, by two properly trained researchers, in a private room, before or after the participant's scheduled medical care.

Participants underwent a structured interview with a mean duration of ∼40 min, where the more intimate and personal questions were asked at the end. The questions addressed sociodemographic, affective-sexual, clinical, laboratory, and antiretroviral treatment variables, and the data were complemented with a review of medical records.

Standardized instruments to assess compliance to treatment, quality of life, and self-efficacy were also used after formal permission of the owner authors. Compliance to treatment was evaluated by the “Cuestionario para la Evaluación de la Adhesión al Tratamiento Antiretroviral” (CEAT-VIH), translated, adapted, and validated for assessment of adherence to antiretroviral treatment in Brazilian PLWHA.¹¹ The overall compliance score ranges from 0 to 100, and it is distributed in five domains (compliance, history of nonadherence, doctor-patient communication, beliefs and expectations about the treatment, and satisfaction with the treatment). Scores above 80 are associated with good clinical, virological, and immunological outcomes.¹¹

The Scale of Self-Efficacy Expectations of Adherence to Antiretroviral Treatment (SEA-ART) was used to assess the expectation of self-efficacy in 21 situations that make it difficult to comply with the antiretroviral prescription. Patients are asked about their expectations of taking prescription drugs. The answers were scored from one to five points, respectively, according to the following classification: “I won't take it,” “I don't think I will take it,” “I don't know,” “I think I will take it,” and “I definitely will to take.” The total score ranges from 21 points to 105 points.¹² A SEA-ART score greater than 101 was associated with reasonable accuracy (AUC 0.80) in discriminating ART adherence in adults living with HIV at 1-month follow-up.¹³

Quality of life was assessed by the HIV/AIDS-targeted quality-of-life instrument (HAT-QoL) translated and validated in Brazilian women living with HIV/AIDS. It is distributed in nine domains: general activities, sexual activities, concern for confidentiality, concern for health, financial concerns, HIV awareness, life satisfaction, medication issues, and trust in the physician. The values were added and weighted, obtaining a scale domain from 0 to 100.¹⁴

To assess adherence to antiretroviral treatment, the pharmacy refill data were recorded in the 6 months before the interview, through the System of Logistics Control of Medicines (SICLOM) from the Brazilian Ministry of Health. The last seven medication refills before the interview date were recorded, or all refills if the patient has been on treatment for <6 months.

The refill dates were recorded in an Excel spreadsheet, and the percentage of treatment covered days in the 6-month period was calculated, as described: (1) if there was no refill, the treatment covered percentage was zero; (2) if there has been one or more refills, the treatment covered percentage will be equal to the number of pills refilled in the period of 180 days, divided by 180 days; and (3) for patients who started treatment in a period of <6 months, the formula was individually adjusted using the sum of refilled pills divided by the total number of days of treatment. The outcome used in the study was adequate adherence to antiretroviral treatment, characterized by the refill of at least 90% of prescribed doses.

An independent double data entry was used to compose the database in Microsoft Excel, with subsequent comparison and correction of typing inconsistencies. Data were analyzed using the Epi Info 7 program. The sample was initially characterized by descriptive statistics. Absolute and relative frequencies were calculated for categorical variables. Continuous variables were described using measures of central tendency and dispersion.

Subsequently, each variable was analyzed for association with adherence to antiretroviral treatment, by refilling of at least 90% of the prescribed doses. Analysis of variance was used for continuous quantitative variables with normal distribution. In case of nonhomogeneous distribution by the Bartlett test of variance, the Kruskal–Wallis test for two groups was performed. For categorical variables, Fisher's exact test was used. The influence of the variable was considered significant when p value was <0.05.

Variables that show significance with p < 0.15 in the univariate analysis were included in a multiple logistic regression model. Continuous variables were dichotomized by the median or cutoff value validated in the literature. In the multi-variate analysis, a dichotomized data sheet with backward selection methodology was used, with variables of p < 0.05 being kept in the model.

Results

The study population consisted of 220 participants, with a mean age of 43 years (20–76 years), being 60.5% male and 50.4% White; 55.4% had completed at least high school; 79.1% reported having a religion; 79.6% had a source of income, with 62.7% having a family income of up to one minimum wage; 59.1% had children; and 81.8% lived with at least one person (Table 1).

Table 1.

Sociodemographic Characteristics of People Living with HIV/AIDS on Antiretroviral Treatment, São Carlos, 2019

Variable	N	%
Age in years, mean (SD)	43.2	(11.2)
Sex, n (%)
Male	133	(60.5)
Gender, n (%)
Male	128	(58.2)
Female	87	(39.5)
Transsexual female	5	(2.3)
Skin color, n (%)
White	111	(50.4)
Brown	79	(35.9)
Black	27	(12.3)
Yellow	3	(1.4)
Education, n (%)
No schooling	7	(3.2)
Elementary school	91	(41.4)
High school	78	(35.4)
University education	34	(15.4)
Postgraduate education	10	(4.6)
Religion, n (%)
Catholic	73	(33.2)
Evangelical	70	(31.8)
There is not	46	(20.9)
Spiritist	18	(8.2)
Other	13	(5.9)
Professional situation, n (%)
Unemployed	60	(27.3)
Autonomous	56	(25.4)
Private company employee	35	(15.9)
Retired	29	(13.3)
Public server	8	(3.6)
Other	32	(14.5)
Family income, n (%)
Up to a minimum wage^a	93	(42.3)
Two to four minimum wages^a	76	(34.6)
Five minimum wages or more^a	6	(2.7)
No income	45	(20.4)
Have children, n (%)	130	(59.1)
Dynamics of living arrangements, n (%)
Alone	40	(18.2)
With one person	60	(27.3)
With two to four people	93	(42.3)
With more than five people	27	(12.2)
Total	220	100

Minimum wage R$954.00 raise in 2018 (source: Brazilian federal government).

N, absolute number; SD, standard deviation.

In the affective-sexual life context, 54.1% reported an active sexual life and 42.7% had a fixed sexual partner. Of the 133 male participants, 54 identified themselves as being MSM, corresponding to 24.5% of the total population. In 91.5% of cases, the partners knew about the diagnosis of HIV infection and 52.1% were serodiscordant. Previous consumption of alcohol or illicit drugs was reported by 44.1% of patients. Regarding the clinical stage of the infection, 54.5% met criteria for AIDS and 86.8% had been diagnosed with HIV infection for >1 year. Most participants (84.1%) had been using antiretroviral medication for >1 year, and 63.2% reported never having stopped the treatment.

The most commonly used treatment regimen was two nucleoside reverse transcriptase inhibitors combined with one non-nucleoside reverse transcriptase inhibitor (37.3%). CD4 counts above 350 cells/mm³ and viral loads below 40 copies/mL were observed in 76.4% and 75.9% of patients, respectively. Regarding the compliance to treatment (CEAT-HIV), only 20% of participants scored 80 points or more. The median on SEA-ART scale was 102 points, and the median of HAT-QoL was 74% (Table 2). Hepatitis C coinfection was observed in 7.3% of participants, hepatitis B serological markers in 2.5%, and past history of tuberculosis in 6%.

Table 2.

Epidemiological, Clinical, and Laboratory Characteristics and Indices of Global Adherence, Self-Efficacy, and Quality of Life in People Living with HIV/AIDS on Antiretroviral Treatment, São Carlos, 2019

Variable	N	%
Active sex life	119	54.1
Fixed sexual partnership	94	42.7
MSM	54	24.5
HIV status disclosed to partner	86	91.5
HIV status of sexual partner
Nonreactive	49	52.1
Reagent	35	37.2
Unknown	10	10.7
Current or former tobacco smoking	75	34.1
Previous alcohol and illicit drug use	97	44.1
Current alcohol and illicit drug use	31	14.1
AIDS diagnosis	120	54.5
Years of diagnosis of HIV infection
≤1 year	29	13.2
2–5 years	71	32.3
6–10 years	47	21.4
11–20 years	58	26.4
>20 years	15	6.7
Last CD4 count (cells/mm³)
>500	149	67.7
351–500	19	8.6
201–350	27	12.3
<201	25	11.4
Last HIV-1 viral load (copies/mL)
< 40	167	75.9
40–500	16	7.3
501–1,000	6	2.7
1,001–100,000	23	10.5
>100,000	8	3.6
Years of antiretroviral use
≤1 year	35	15.9
2–5 years	86	39.1
6–10 years	40	18.2
11–20 years	53	24.1
>20 years	6	2.7
ART
2ITRN +1II	40	18.2
2ITRN +1ITRNN	82	37.3
2ITRN +2IP	77	35.0
Others	21	9.5
Past history of ART discontinuation
No	139	63.2
Yes, on their own	74	33.6
Yes, by medical advice	7	3.2
Indexes
Global Adhesion Index (CEAT) ≥80 points	44	20.0
Self-Efficacy Expectations Score >101 points	111	50.5
HAT-QoL total weighted ≥74%	112	50.9
Adherence to ART^a	136	61.8
Total	220	100

Adherence = Pharmacy refill of at least 90% of prescribed doses in the last 6 months.

ART, antiretroviral therapy; HAT-QoL, HIV/AIDS-targeted quality-of-life instrument; MSM, men who have sex with men; N, absolute number.

Adequate adherence to ART by pharmacy refill data was observed in 61.8% of the participants. Factors associated with adequate adherence in the univariate analysis were as follows: living alone, not being sexually active, being MSM, not being a smoker, having a CD4 count greater than 350 cells/mm³, having an undetectable viral load, and having 102 points or more in the Self-efficacy Expectation Scale for Adherence to Antiretroviral Treatment (Table 3).

Table 3.

Univariate Analysis of Factors Possibly Associated with Adherence to Antiretroviral Therapy in People Living with HIV/AIDS, São Carlos, 2019

Variable	N°	Total	Adherence to ART^a	p ^b	OR	95% CI
Male	86	133	64.7%	0.3213	1.3540	0.7780–2.3566
White skin color	70	111	63.1%	0.7815	1.1123	0.6455–1.9168
University education	31	44	70.5%	0.2258	1.6125	0.7894–3.2936
Source of income	112	175	64.0%	0.2287	1.5556	0.8024–3.0158
Living alone	31	40	77.5%	0.0302	2.4603	1.1065–5.4707
Having children	74	130	56.9%	0.0902	0.5968	0.3390–1.0504
Having a religion	109	174	62.6%	0.3721	1.1801	0.6084–2.2887
Active sex life	65	119	54.6%	0.0184	0.5086	0.2908–0.8895
Fixed sexual partnership	53	94	56.4%	0.1629	0.6697	0.3866–1.1600
MSM	41	54	75.9%	0.0156	2.3571	1.1757–4.7254
HIV status disclosed to partner	48	86	55.6%	1.0000	0.7579	0.1702–3.3740
HIV infected sexual partner	17	35	48.6%	0.2849	0.6034	0.2593–1.4040
Smoking	36	75	48.0%	0.0033	0.4154	0.2341–0.7371
Psychoactive substance use	53	97	54.6%	0.0689	0.5805	0.3350–1.0058
Protease inhibitor treatment	54	97	55.7%	0.1239	0.6279	0.3628–1.0869
Past history of ART discontinuation	31	81	38.3%	0.0000	0.2008	0.1111–0.3629
AIDS diagnosis	67	120	55.8%	0.0516	0.5680	0.3256–0.9906
Current symptoms	60	95	63.2%	0.7799	1.1053	0.6375–1.9161
CD4 ≥ 350 cells/mm³	112	168	66.7%	0.0092	2.3333	1.2395–4.3924
Viral load below 40 copies/mL	120	167	71.9%	0.0000	5.9043	3.0016–11.6138
CEAT-HIV ≥80 points	31	44	70.5%	0.2258	1.6125	0.7894–3.2936
Self-efficacy expectations score >101 points	77	111	69.4%	0.0261	1.9192	1.1050–3.3336
HAT-QoL total ≥74.0%	75	112	67.0%	0.1274	1.5618	0.9033–2.7003

Pharmacy refill of at least 90% of prescribed doses in the last 6 months.

Fisher's exact test.

ART, antiretroviral therapy; CI, confidence interval; HAT-QoL, HIV/AIDS-targeted quality–of-life instrument; OR, odds ratio.

For multiple logistic regression, the following characteristics were tested in the predictive model of adherence: male gender; White color; living alone; having children; having higher education; having income; being sexually active; being MSM; being a smoker; using psychoactive substance; AIDS clinical stage; last CD4 count ≥350 cell/mm³; use of protease inhibitor; self-efficacy expectation for adherence ≥102 points; and HAT-QoL score ≥74%. It was decided not to include, in the model, the report of treatment dropout and of currently having an undetectable viral load, as they are per se information on adherence. Living alone (p = 0.0214), not having an active sexual life (p = 0.0088), not being a smoker (p = 0.0015), having a CD4 count ≥350 cells/mm³ (p = 0.0096), and having a SEA-ART score of 102 or more (p = 0.0324) (Table 4) remained in the final model.

Table 4.

Multiple Logistic Regression of Factors Associated with Adherence to Antiretroviral Therapy^a in People Living with HIV/AIDS, São Carlos, 2019

Variable	Adjusted odds ratio	(95% CI)	p
Living alone	2.7922	1.1647–6.6940	0.0214
Active sex life	0.4309	0.2296–0.8086	0.0088
Smoking	0.3613	0.1927–0.6775	0.0015
CD4 ≥ 350 cells/mm³	2.5017	1.2496–5.0085	0.0096
Self-efficacy expectations score >101 points	1.9362	1.0569–3.5470	0.0324

Pharmacy refill of at least 90% of prescribed doses in the last 6 months.

CI, confidence interval.

Discussion

In São Carlos, SP, Brazil, only 61.8% of adults living with HIV/AIDS had at least 90% of days covered by the prescribed antiretroviral medication during a 6-month follow-up period. Even with this low adherence rate, there was an adequate virologic response with an undetectable HIV plasma load in 71.9% of patients. Previous studies showed the need to adhere to at least 80% of doses for adequate control of viremia.^6,15

The difficulty in standardizing the criteria for adherence to antiretroviral treatment makes it difficult to compare study methodologies and results. Studies that used pharmacy refill data as the method to monitor adherence to ART diagnosed adherence rates between 14.2% and 83.6%,^7,15
–17 lower values than those found in studies that assessed self-reported adherence, which reported rates between 53.6% and 92.4%.^{18

–25} Another strategy is to use scales that associate self-reported adherence to previous viral load measurements.^26,27 Quantification of antiretrovirals in dried blood spots as a measure of short-term adherence can also be used to predict future viremia in patients with overestimated recent adherence by self-report.²⁸ Preliminary study used a mobile application [Mobile Interactive Supervised Therapy (MIST)] to improve medication adherence to antiretroviral treatment. Adherence was assessed using an electronic medical device, the MEMS, but there was no impact due to the small sample size and high adherence.²⁹

The most frequently associated factors with low adherence to antiretroviral treatment are illegal drug and alcohol use^7,21,23,27 and occurrences of adverse effects;^7,21 low educational level,^7,19,27 younger age,^7,15,19,23 and difficulties to attend the outpatient medical appointments;^19,27 having some level of depression or using psychiatric medications;^20,27 and Black ethnicity.²⁰

In this study, smoking was the main factor associated with nonadherence, both in the univariate analysis [odds ratio (OR) 0.4154] and after adjustment for confounding variables by multiple regression (adjusted OR 0.3613). This finding reinforces the recommendation to adopt healthy lifestyle habits to improve tolerance to antiretroviral treatment.^9,22,30

More recently, evidence has emerged that fear of disclosing HIV status could lead to difficulty adherence to treatment.²² This could be the reason that characteristics living alone and not having an active sexual life have been associated with better adherence in our study. Nevertheless, in national studies carried out in large cities, social and family support were associated with better adherence.^16,31 In large centers, perhaps anonymity reduces the possibility of an individual being negatively identified and judged, and the social support network usually works in a beneficial way.^9,20,22 In a medium-sized city in the interior of the state of São Paulo, a reserved lifestyle may provide the necessary privacy for good adherence to antiretroviral treatment. Corroborating our findings, in a study carried out in 2019, in a medium-sized city in Asia, people who participate in larger family structures showed lower adherence to treatment.²¹

Self-efficacy expectation of adherence, that is the capability of the patient to overcome the difficulties of antiretroviral treatment, also seems to be associated with greater adherence to ART (adjusted OR 1.9362). A study carried out in 2015, in the countryside of Rio Grande do Sul, Brazil, identified that the social support perceived by the patient is associated with their expectation of self-efficacy. Both factors help the patient to adhere to the service and ART, and consequently to maintain the response to treatment.¹⁶ Likewise, the way in which the diagnosis of HIV infection is revealed to the patient can affect adherence to ART through the targeting of social support and possible self-efficacy strategies.²³

Ease of dosing and good tolerability have been factors associated with improved adherence to antiretroviral treatment.^7,9,16,21,22 In our study, the most used antiretroviral regimens were two nucleoside analog reverse transcriptase inhibitors associated with a non-nucleoside reverse transcriptase inhibitor (37%), followed by schemes in which the third drug was a protease inhibitor (35%). Only 18% of participants were using viral integrase inhibitors, drugs with a better safety and tolerability profile. Probably, with the current greater availability of once-daily regimens with integrase inhibitors, the adherence rate should improve.³⁰ Apparently, people treated with an integrase strand transfer inhibitor regimen are more likely to adhere to antiretroviral treatment.¹⁵

Institutional data on low adherence to treatment should prompt reflection on policies and resources available to professionals working in this context, including implementation of a therapy facilitation strategy, reduction of adverse effects, strengthening of bonds, and user involvement to promote better adherence.^26,30 Especially among younger people and newcomers to therapy, additional support such as answering questions about the treatment and the disease, identifying demands as well as their appropriate referrals, and more frequent monitoring can improve adherence.¹⁵

In this sense, the involvement of community health workers (CHW) could be beneficial in supporting adherence to ART. However, it is necessary to consider the HIV stigma, and CHWs must be aware of the importance of secrecy and privacy, and they must be trained in competencies such as communication and interpersonal skills, facilitating trust, and the relationship with the client.^32,33

A significant percentage of PLWHA in this study (38%) had low adherence to ART in the last 6 months. The short-, medium-, and long-term consequences are lack of virological control, immunological damage, increased morbidity, lethality, and transmissibility.^15,30

This study has some possible limitations, such as a sample selection bias, since people who dropped out of treatment did not have the chance to participate, which may have increased the rate of adherence to treatment, in addition to an error in the estimation of adherence by pharmacy refill data, as the participant may in fact not have ingested all the doses.

Adults living with HIV/AIDS in São Carlos had difficulty adhering to antiretroviral treatment. Apparently, in medium-sized cities, effective measures to guarantee secrecy and privacy regarding the diagnosis of HIV infection can have benefits in terms of adherence to antiretroviral treatment. Likewise, adherence is also improved by the encouragement of healthy lifestyle habits and the promotion of self-efficacy tools, such as knowledge about the evolution of infection, the mechanism of action of medications, and the role of adherence in therapeutic response, in addition to structuring social and emotional support.

Footnotes

Authors' Contributions

I.G.d.O.B. and A.A.N. conceived the study; I.G.d.O.B., S.D.S.S., and A.A.N. designed the study; I.G.d.O.B. collected the data and conducted the interviews; A.A.N. and S.D.S.S. supervised the methodology; I.G.d.O.B. and S.D.S.S. conducted the analysis; I.G.d.O.B. and S.D.S.S. wrote the original draft; and I.G.d.O.B., S.D.S.S. and A.A.N. reviewed and edited the article.

Acknowledgments

We are grateful for the assistance of Kamily Costa and Ilda Imasato in the collection of data. We would like to acknowledge the support of the São Carlos Chronic Infection Care Center team in the implementation of study and data collection: Cintia Martins Ruggiero, Conceição Walsimary Justa Uchoa, Ana Maria Zabeu, Márcia Milani, Vera Lúcia Simões Campos, Calógeras Antônio de Albergaria Barbosa, Bárbara Rezende Martins, Robson Poul L Tiossi, Alessandra Cristina de Oliveira, and Joselaine Aparecida da Silva.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001.

References

UNAIDS. UNAIDS DATA 2021. Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2021. Available at: www.unaids.org/sites/default/files/media_asset/JC3032_AIDS_Data_book_2021_En.pdf. Licence: CC BY-NC-SA 3.0 IGO (Last accessed April 15, 2022 ).

Mangal

, Pascom

ARP

, Vesga

, et al. Estimating HIV incidence from surveillance data indicates a second wave of infections in Brazil. Epidemics, 2019; 27:77–85.

BRAZIL. Ministry of Health. Health Surveillance Department. Department of STD, AIDS and Viral Hepatitis. [Adherence to antiretroviral treatment in Brazil: Collection of Project After studies]. Brasilia: Ministry of Health; 2010, p. 48.

Iacob

, Iacob

, Jugulete

. Improving the adherence to antiretroviral therapy, a difficult but essential task for a successful HIV treatment-clinical points of view and practical considerations. Front Pharmacol, 2017; 8:831.

Carvalho

, Barroso

, Coelho

, et al. Factors associated with antiretroviral therapy adherence in adults: An integrative review of literature. Cien Saude Colet, 2019; 24:2543–2555.

Bonolo

PdF

, Gomes

RRdFM

, Guimarães

MDC

. Adherence to antiretroviral therapy (HIV/AIDS): Factors associated and adherence strategies. Epidemiol Serv Saúde, 2007; 16:267–278.

Silva

, Dourado

, Brito

, et al. Factors associated with non-adherence to antiretroviral therapy in adults with AIDS in the first six months of treatment in Salvador, Bahia State, Brazil. Cad Saude Publica, 2015; 31:1188–1198.

Val

JLDd

, Bonizio

MLF

, Silva

PAd

, et al. Cascata de Cuidado Contínuo da Infecção Por HIV: Coinfecções e Perda de Seguimento. Brazil J Infect Dis, 2018; 22:115.

Costa

, Torres

, Coelho

, et al. Adherence to antiretroviral therapy for HIV/AIDS in Latin America and the Caribbean: Systematic review and meta-analysis. J Int AIDS Soc, 2018; 21:e25066.

10.

UNAIDS. Reaching out to men and boys. Addressing a blind spot in the response to HIV Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2017. Available at: https://www.unaids.org/sites/default/files/media_asset/blind_spot_en.pdf (Last accessed June 2019 ).

11.

Remor

, Milner-Moskovics

, Preussler

. [Brazilian adaptation of the Assessment of Adherence to Antiretroviral Therapy Questionnaire]. Rev Saude Publica, 2007; 41:685–694.

12.

Leite

JCdC

, Drachler

MdL

, Centeno

, et al. Development of a scale of self-efficacy for adherence to antiretroviral therapy. Psicologia: Reflexão e Crítica, 2002; 15:121–133.

13.

Drachler

MeL

, Drachler

, Teixeira

, et al. The scale of self-efficacy expectations of adherence to antiretroviral treatment: A tool for identifying risk for non-adherence to treatment for HIV. PLoS One, 2016; 11:e0147443.

14.

Galvão

, Cerqueira

, Marcondes-Machado

. [Evaluation of quality of life among women with HIV/AIDS using HAT-QoL]. Cad Saude Publica, 2004; 20:430–437.

15.

de Oliveira Costa

, Schaffer

, Medland

, et al. Adherence to antiretroviral regimens in Australia: A Nationwide Cohort Study. AIDS Patient Care STDS, 2020; 34:81–91.

16.

dos Santos

, Drumond

, Gomes

AaS

, et al. [Barriers and facilitators aspects of adherence to antiretroviral therapy in Belo Horizonte-MG]. Rev Bras Enferm, 2011; 64:1028–1037.

17.

McComsey

, Lingohr-Smith

, Rogers

, et al. Real-world adherence to antiretroviral therapy among HIV-1 patients across the United States. Adv Ther, 2021; 38:4961–4974.

18.

de Carvalho

, Duarte

, Merchán-Hamann

, et al. [Predictors of compliance with highly active antiretroviral therapy in Brasília, Distrito Federal, Brazil, 1999–2000]. Cad Saude Publica, 2003; 19:593–604.

19.

Foresto

, Melo

, Costa

CRB

, et al. Adherence to antiretroviral therapy by people living with HIV/AIDS in a municipality of São Paulo. Rev Gaucha Enferm, 2017; 38:e63158.

20.

Moraes

, Casseb

. Depression and adherence to antiretroviral treatment in HIV-positive men in São Paulo, the largest city in South America: Social and psychological implications. Clinics (Sao Paulo), 2017; 72:743–749.

21.

Neupane

, Dhungana

, Ghimire

. Adherence to antiretroviral treatment and associated factors among people living with HIV and AIDS in CHITWAN, Nepal. BMC Public Health, 2019; 19:720.

22.

Chirambo

, Valeta

, Banda Kamanga

, et al. Factors influencing adherence to antiretroviral treatment among adults accessing care from private health facilities in Malawi. BMC Public Health, 2019; 19:1382.

23.

, Li

, Zhou

, et al. HIV disclosure to family members and medication adherence: Role of social support and self-efficacy. AIDS Behav, 2020; 24:45–54.

24.

O'Halloran Leach

, Lu

, Caballero

, et al. Defining the optimal cut-point of self-reported ART adherence to achieve viral suppression in the era of contemporary HIV therapy: A cross-sectional study. AIDS Res Ther, 2021; 18:36.

25.

Mbah

, Iroezindu

, Esber

, et al. Assessing the impact of HIV support groups on antiretroviral therapy adherence and viral suppression in the African cohort study. BMC Infect Dis, 2021; 21:694.

26.

Silva

RAR

, Nelson

ARC

, Duarte

FHdS

, et al. Evaluation of adherence to antiretroviral therapy for AIDS patients. Rev Fund Care Online, 2017; 9:15–20.

27.

Zuge

, Primeira

, Remor

, et al. Factors associated to the adherence to antiretroviral treatment in HIV-infected adults: Cross-sectional study. Rev Enferm UFSM, 2017; 7:577–589.

28.

Morrow

, MaWhinney

, Coyle

, et al. Emtricitabine triphosphate in dried blood spots predicts future viremia in persons with HIV and identifies mismatch with self-reported adherence. AIDS, 2021; 35:1949–1956.

29.

Pang

, Molton

, Ooi

, et al. Preliminary effects of a mobile interactive supervised therapy intervention on people living with HIV: Pilot randomized controlled trial. JMIR Mhealth Uhealth, 2020; 8:e15702.

30.

BRAZIL. Ministry of Health. Secretary of Surveillance in Health. Department of Surveillance, Prevention and Control of Sexually Transmitted Infections, HIV/AIDS and Viral Hepatitis. [Clinical Protocol and Therapeutic Guidelines for the Management of HIV Infection in Adults]. 1 ed. Ministry of Health, ed. Brasilia: Ministry of Health; 2018.

31.

Padoin

SMdM

, Marchi

MCd

, Santos

WMd

, et al. The influence of marital status in social support in people infected by HIV. Revista de Enfermagem do Centro-Oeste Mineiro, 2018; 8:[1–6 pp.]. Available at: http://seer.ufsj.edu.br/index.php/recom/article/view/2485/1930 (Last accessed March 1, 2022 ).

32.

Knettel

, Wanda

, Amiri

, et al. Assessing the influence of community health worker support on early antiretroviral therapy adherence, anticipated stigma, and mental health among people living with HIV in Tanzania. AIDS Patient Care STDS, 2021; 35:308–317.

33.

Davoust

, Drainoni

, Baughman

, et al. “He Gave Me Spirit and Hope”: Client experiences with the implementation of community health worker programs in HIV Care. AIDS Patient Care STDS, 2021; 35:318–326.