To analyze how clinical and social events may impact adherence to antiretroviral treatment for HIV. This is a historical cohort study with 528 patients who underwent treatment for HIV in a specialized care service in Alvorada, RS. A total of 3429 queries executed between the years 2004 and 2017 were analyzed. For each visit, data on treatment characteristics and the patients’ clinical picture were collected. Adherence, as measured by patients’ self-report, was the endpoint of the study. The logistic regression model via generalized estimating equations was used for estimating the associations. 67.8% of the patients analyzed have up to 8 years of education and 24.8% have a history of crack and/or cocaine use. Among men, being asymptomatic , having more than 8 years of education , and never having used crack  were associated with adherence. For women, being older than 24 years , never having used cocaine  and being pregnant  increased the odds of adherence. In addition to defined sociodemographic characteristics, one-off events that may occur in the trajectory of patients on long treatment, such as starting a new pregnancy and not having symptoms, can impact patients’ chances of treatment adherence. Successful treatment requires commitment to daily medication, subject to possible side effects. With correct adherence to ART, a reduction in viral load to undetectable levels is expected, providing benefits for the quality of life of patients and hindering the sexual transmission of HIV to other people.Non-adherence to HIV antiretroviral therapy (ART) is a multifactorial phenomenon present in both rich and poor countries. However, the complexity of adherence to long term treatment also occurs because of the possibility of changes in the frequency of adherence according to one-off events in the patients’ lives, for example, a new pregnancy.There are several studies investigating sociodemographic characteristics associated with adherence to antiretroviral treatment. The literature on the topic has shown, for example, that factors such as female gender, young age, white color/race, and high income and education are associated with greater chances of adherence to ART. Analyzing patient adherence to ART, of the 637,000 patients who recorded at least one drug dispensation in 2018, approximately 17% had less than 80% adherence to antiretroviral drugs and 8% were classified as dropouts. Given the context presented, this study seeks to understand how clinical and social events that present themselves in the trajectory of individuals can impact adherence to antiretroviral treatment for HIV.In Brazil, antiretroviral treatment for HIV has been universally available through the Brazilian Unified Health System (SUS) since 1996. Despite this, it is estimated that in 2018, only 66% of the 900,000 people living with HIV/AIDS (PLHIV) in the country were on treatment, with PLWHA in the municipality of Alvorada, located in the Metropolitan Region of Porto Alegre. The cohort has information from 1093 patients who underwent HIV treatment at the only Specialized Care Service (SAE) in the study municipality. The data were systematized by collecting information from the consultations available in the SAE medical records.The study data come from a historical cohort, called the Alvorada CohortThe units of analysis for the study were the patients’ consultations. Initially, the cohort contained 10361 queries. For this work, we selected the consultations whose patients: (1) had prescribed medication for HIV treatment; (2) were 18 years or older; and (3) had attended the consultation. Following these criteria, 2177 consultations of patients who had no prescription for the drugs, 326 consultations of patients under 18 years of age, and 1770 consultations in which the patient did not show up at the SAE on the scheduled date were excluded. Then, exclusively those with information on ART adherence, clinical presentation, opportunistic infection, and hospitalization were selected. With this, the final sample of the study was 3,429 consultations performed between 2004 and 2017.The endpoint of the study was patient adherence to ART. It was measured from the patients’ self-report at each visit, in which the health professional in charge would ask the patient about the use or non-use of the prescribed medications. In the data collection, adherence was classified as “regular adherence”, “irregular adherence”, or “non-adherent”. For this study, the variable was recoded into two categories: “in compliance”, when the patient is taking the medication regularly, or “in poor compliance”, when the patient is in irregular or non-adherent compliance.Also measured in all consultations, the variables used to characterize the treatment and clinical picture of patients were: clinical presentation (symptomatic/asymptomatic), infection by opportunistic disease (yes/no), hospital admission (yes/no) and pregnancy (yes/no), in the case of women. The variable “hospital admission” considers whether the patient was admitted exclusively because of HIV complications.Sociodemographic and behavioral information was collected only once at the time of patients’ entry to the SAE. They are: sex , education (by ranges of years studied), age (in years), marital status (single/dating/married or living together), HIV exposure category , alcohol abuse (yes/no), cocaine use (yes/no), and crack use (yes/no).For the variable “alcohol abuse”, only the cases in which the individual had experienced alcoholism at some point in his or her life were considered. Cases in which the person reports occasional alcohol use were not considered. For the variables “crack use” and “cocaine use”, the cases in which the individuals reported using or having already used the drugs once in their lives were considered..From factors such as “education” and “age” variables were created for analysis based on specific categories and values. For education, we created the dichotomous variable “high school”, whose categories represent: (1) having up to 8 years of study; and (2) having more than 8 years of study . For age, two age categories were created: (1) people aged 18 to 24, considered young; and (2) people over 24. The distinction was made taking into consideration the various studies on the topic that indicate that young people have lower chances of adhering to ARTStudent’s t-test and comparisons of proportions using Pearson’s chi-square-based test orFisher’s exact test.The sociodemographic and behavioral characteristics of the patients were presented separately for men and women, as well as the frequencies of events  recorded throughout the follow-up. Comparisons of means were performed usingThe logistic regression model was used to assess the associations between clinical, sociodemographic, and behavioral factors and adherence to ART. To account for correlations between different visits to the same patient, generalized estimating equations (GEE) approach was used. As study factors, we analyzed: clinical presentation, hospitalization, opportunistic infection, and pregnancy . Sociodemographic and behavioral variables  were used as controls in the models.The models were stratified by sex because of the presence of the variable “pregnancy”, included only in the analysis of women. For both genders, three models were constructed aiming to estimate the odds ratios (OR) of adherence to antiretroviral treatment. The first model considers only the exposures under study; the second includes sociodemographic control variables; and the third adds drug use variables.The analyses were performed on the Statistical Package for the Social Sciences (SPSS) software, version 18, using the 5% significance level. The project was approved by the Research Ethics Committee of Universidade Federal do Rio Grande do Sul (CEP/UFRGS) and the researchers signed a term of commitment for the use of data.The sociodemographic and behavioral characteristics of the patients are presented inAnalyzing the use of licit and illicit drugs, the history of use for men is higher than for women: 32.6% of men and 12.4% of women have a history of alcohol abuse (p < 0.001); 22.6% of men and 12.8% of women have a history of cocaine use (p = 0.003), and 14.4% of men have a history of crack use, while in women the proportion is 10.5% (p = 0.167).The number of records analyzed lacking information regarding the category of HIV exposure of the patients was significant: 39.6% among men and 14.3% among women. About 84.9% of the women in the sample acquired HIV through heterosexual intercourse - which represents almost all of the female patients with available information. In men, besides the large proportion of medical records without information, 38.9% of patients reported infection through heterosexual intercourse, 17.8% through homosexual intercourse and 3.7% due to injecting drug use (p < 0.001).As for marital status, the proportions were similar between men and women: 51.9% of men and 45.7% of women were single, while 29.1% of men and 32.7% of women were married or living together with their partner. The education variable shows that most participants in the sample have 5 to 8 years of schooling, and that the proportion of people with up to 4 years of schooling was 14.4% for men and 16.3% for women. The variables education and marital status showed no statistically significant difference between the groups.In model 2, with sociodemographic variables, being asymptomatic  and no record of hospitalization  there were still increased odds of adherence for men, although the second variable lost statistical significance. In this model, patients with more than 8 years of education have increased odds of adherence . In model 3, only clinical presentation remained significant, increasing the odds of adherence by about 43% in the absence of symptoms . Regarding drug use, never having used crack appears as a factor associated with adherence .Adding the sociodemographic variables, model 2 remains with similar results to the previous one, in which pregnancy  increases the odds of adherence by almost three times. The variable age also shows an association, increasing the chances in people over 24 years old . Finally, in model 3, pregnant patients at the consultation have more than a threefold increase in the odds of adherence , while not being young , and not using cocaine  significantly increase the odds of adhering.. However, it is not only sociodemographic characteristics that can impact treatment adherence, since one-off events that occur throughout patients’ lives can also influence these chances. These events include: the occurrence of a pregnancy; hospitalization; infection by an opportunistic disease; and clinical presentation.Several studies point to sociodemographic and behavioral factors that may influence patients’ chances of adhering to ART. In many of these papers, adherence is treated in a “definitive” and not very flexible way: the individual is either adherent or not.In this study, pregnant women have up to a 3.28 greater chance of adhering to ART compared to women who are not pregnant. The literature points out that pregnancy can impact adherence because: (1) many women start treatment together with prenatal care, in which part of them discovers their HIV serology; (2) there is an attention of policies for this population, focused mainly on maternal-infant care; (3) there are feelings and fears, on the part of the pregnant woman, of transmitting HIV to her child. On the other hand, several studies show that after delivery, the chances of treatment failure or even abandonment increase.In fact, several incentives are used in prenatal care to stimulate adherence to ART, for example: greater attention from health teams to pregnant women; strict monitoring of patients to avoid vertical transmission of HIV; active search for pregnant women who do not attend health services, etc. Thus, it is expected that these incentives stimulate an increase in adherence during pregnancy. In another analysis of data from the Alvorada cohort, it was evidenced that pregnant women take less time to reach an undetectable HIV viral load when compared to non-pregnant patientsThis indicates that pregnancy can be a one-time event that positively impacts treatment adherence precisely because of the way this population is monitored during prenatal care, when they receive more attention from health policies and greater encouragement to build the link with health services. After pregnancy ends, however, these stimuli are weakened..The results of this study contribute to the understanding of the effect of pregnancy on the lives of women living with HIV and are relevant especially when analyzing the incidence of HIV diagnoses in pregnant women in the country and in the metropolitan region where Alvorada is located. In Brazil, the HIV detection rate in pregnant women has grown 38.1% in the last 10 years. Among Brazilian capitals, Porto Alegre recorded the highest HIV detection rate in pregnant women in the country in 2018.These analyses suggest that the men in the sample seek to maintain correct adherence even when they do not have HIV complications, unlike other studies of chronic diseases that show that the absence of symptoms makes patients stop taking medication due to lack of understanding of the course of the disease or because they believe that it is no longer necessary to take the drugs.However, this result can also be analyzed through the direct relationship between adherence to ART and the expected symptomatic improvement of patients, since the effectiveness of treatment and the absence of symptoms depend directly on adherence. Studies show that to ensure viral suppression and a significant reduction in the risk of death, patients must correctly take at least 95% of the prescribed medication. On the other hand, presenting symptoms can also make the patient choose to abandon treatment because they believe that the worsening symptoms are related to the medications.Analyzing the relationship between clinical presentation and adherence in the literature, papers show that the absence of symptoms can be a reason to adhere to medication, although symptomatic improvement is, in some cases, associated with treatment abandonment, since the patient may judge that they no longer needs the medication and daily choice to use them or not is common in long treatments such as chronic diseases. After the development of antiretroviral therapy, AIDS underwent a transformation on its aspect from acute to chronic disease. That is, if before the disease was associated with the certainty of death, today it is possible to live with HIV normally . As with other chronic diseases, regular treatment compliance may not occur even with symptoms of the disease. It is also hindered because, in some cases, patients do not see treatment as being a long and continuous process, which is a characteristic of chronic diseases.This kind of “self-management” of the medications . Besides the difficulties in adhering, recent data have shown that young people are one of the groups that have had the highest increase in HIV detection rates in recent years, highlighting the vulnerability of them in the current scenario of the epidemic. Among young people aged 20 to 24, the detection rate has increased 94.6% in the last decade.Among the sociodemographic and behavioral variables, an association was found between age and adherence to ART, where being older than 24 years increases the chance of adhering to ART by up to 82% among women. There are several studies investigating factors associated with adherence to ART, pointing out that young people are less likely to adhere to both antiretroviral treatment and other chronic diseases. An extensive review of the literature developed on the subject shows that several cases are reported in which substance use appears associated with HIV complications, since they reduce the chances of patient adherence to antiretroviral treatment. In this study, it was found that having no history of crack and cocaine use significantly increases the chances of adherence. Other research has shown that drug use has a negative effect on the chances of adhering, both in men and women and in rich or poor countries. Studies and reviews involving the use of ART also show that people who use drugs have greater difficulties in adherence, even with the presence of symptoms and clinical pictures evolving to AIDS.The use of drugs such as crack and cocaine is also mentioned in the literature several times as a factor that has a major impact on ART.It should be noted that, unlike other studies, our sample was composed of consultations, which may be related to the high adherence found in the study (86.1% in men’s consultations and 83.9% in women’s consultations). It is expected that patients who attend appointments are more likely to follow treatment, while people with irregular adherence tend to miss more appointments or even discontinue treatment, making the proportion of appointments with adhering patients in the sample naturally increase. In addition, 1,170 consultations  were excluded from the analyses because the patients did not attend. Finally, another factor that may be impacting this high proportion of adherence consultations is the very way in which the variable was measured. In some cases, patients’ self-report may be overestimated due to concern about not disappointing the healthcare professionals providing the care. In addition, the municipality scores lower than the national average in education and development statistics.The study sample includes a socially vulnerable population. More than half of the patients have up to eight years of education, which is equivalent to elementary school, and about a quarter have a history of crack and/or cocaine use. Alvorada is located in the Metropolitan Region of Porto Alegre and is the 2nd municipality with the lowest GDP per capita in Rio Grande do Sul.This study used secondary data, which limits the data analysis to only information recorded in the medical records. In this sense, other characteristics associated with adherence discussed in the literature were not explored. In addition, among the variables selected for the analyses, in many queries the information was not found, significantly reducing the number of units of analysis in the sample. It is also important to reiterate that the way adherence was measured may influence the results, since patients may refer greater adherence to health professionals in order not to disappoint themOn the other hand, the great contribution of the study is to look at adherence in the patients’ trajectory. This perspective allowed us to demonstrate how some specific events that occur in the trajectory of patients in situations of vulnerability can impact treatment adherence. The influence of pregnancy on adherence suggests that prenatal care is important for the treatment of pregnant women living with HIV. However, just like pregnancy, the prenatal period is transient, and does not include all women.In this sense, new strategies that stimulate permanent adherence deserve to be thought of to guarantee therapeutic success. Especially in the case of women, it is crucial to change strategies and implement public policies that support women also after pregnancy, when the chance of adherence is reduced. In addition, measures to strengthen the retention of postpartum women in health services  need to be encouraged to control the risk of vertical transmission through breastfeeding, often neglected by health policies.The results of the paper point out that a good clinical presentation increases the chances of adherence to ART for men in the sample. In this sense, our data indicate the importance of integrating HIV prevention and care strategies, since patients with good compliance tend to have undetectable viral load, significantly decreasing the chances of virus transmission. . O sucesso do tratamento exige comprometimento à medicação diária, sujeita a possíveis efeitos colaterais. Em correta adesão ao TARV, espera-se uma redução na carga viral a níveis indetectáveis, proporcionando, além dos benefícios para a qualidade de vida dos pacientes, uma redução no risco de transmissão sexual do HIV para outras pessoas.A não adesão à terapia antirretroviral para o HIV (TARV) é um fenômeno multifatorial presente tanto em países ricos como em pobres. No entanto, a complexidade da aderência a tratamentos longos também ocorre devido à possibilidade de mudanças na frequência da adesão de acordo com eventos pontuais na vida dos pacientes, por exemplo, uma nova gestação.Diversos são os estudos que investigam características sociodemográficas associadas à adesão ao tratamento antirretroviral. A literatura sobre o tema tem mostrado, por exemplo, que fatores como gênero feminino, idade jovem, cor/raça branca, e alta renda e escolaridade estão associados a maiores chances na adesão ao TARV. Analisando a aderência dos pacientes ao TARV, dos 637 mil pacientes que registraram pelo menos uma dispensação de medicamento em 2018, aproximadamente 17% apresentaram adesão inferior a 80% dos medicamentos antirretrovirais e 8% foram classificados como em abandono. Frente ao contexto apresentado, este estudo procura compreender como eventos clínicos e sociais que se apresentam na trajetória dos indivíduos podem impactar na adesão ao tratamento antirretroviral para o HIV.No Brasil, o tratamento antirretroviral para o HIV está disponível pelo Sistema Único de Saúde (SUS), de forma universal, desde 1996. Apesar disso, estima-se que, em 2018, somente 66% das 900 mil pessoas vivendo com HIV/aids (PVHA) no país estavam em tratamento, com PVHA no município de Alvorada, localizado na Região Metropolitana de Porto Alegre. A coorte possui informações de 1093 pacientes que realizaram tratamento para o HIV no único Serviço de Assistência Especializada (SAE) do município do estudo. Os dados foram sistematizados através de uma coleta realizada a partir das informações das consultas disponíveis nos prontuários do SAE.Os dados do estudo são provenientes de uma coorte histórica, chamada Coorte de AlvoradaAs unidades de análises do estudo foram as consultas dos pacientes. Inicialmente, a coorte continha 10361 consultas. Para esse trabalho, foram selecionadas as consultas cujos pacientes: (1) possuíam medicação prescrita para o tratamento do HIV; (2) tinham 18 anos ou mais; e (3) haviam comparecido à consulta. Seguindo estes critérios, foram excluídas 2177 consultas de pacientes que não possuíam prescrição aos medicamentos, 326 consultas de pacientes com menos de 18 anos de idade, e 1770 consultas em que o paciente não compareceu ao SAE na data agendada. Em seguida, foram selecionadas somente aquelas que obrigatoriamente possuíam informações de adesão ao TARV, apresentação clínica, registro de infecção oportunista e hospitalização. Com isso, a amostra final do estudo foi de 3.429 consultas realizadas entre 2004 e 2017.O desfecho do estudo foi a adesão dos pacientes ao TARV. Ela foi aferida a partir do autorrelato dos pacientes em cada consulta, em que o profissional de saúde responsável questionava o paciente a respeito da utilização ou não dos medicamentos prescritos. Na coleta de dados, a adesão foi classificada como “adesão regular”, “irregular” ou “não aderente”. Para este estudo, a variável foi recodificada em duas categorias: “em adesão”, quando o paciente está tomando a medicação regularmente, ou “em má adesão”, quando o paciente está em adesão irregular ou não aderente.Também aferidas em todas as consultas, as variáveis utilizadas para caracterizar o tratamento e quadro clínico dos pacientes foram: apresentação clínica (sintomático/assintomático), infecção por doença oportunista (sim/não), internação hospitalar (sim/não) e gestação (sim/não), no caso das mulheres. A variável “internação hospitalar” considera se o paciente foi internado exclusivamente por conta de complicações em função do HIV.Informações sociodemográficas e comportamentais foram coletadas apenas uma vez no momento de entrada dos pacientes ao SAE. São elas: sexo (homem/mulher), escolaridade (por faixas de anos estudados), idade (em anos), situação conjugal (solteiro/namorando/casado ou morando junto), categoria de exposição ao HIV , abuso de álcool (sim/não), uso de cocaína (sim/não) e uso de crack (sim/não).Para a variável “abuso de álcool”, foram considerados apenas os casos em que o indivíduo passou por um quadro de etilismo em algum momento da vida. Não foram considerados casos em que a pessoa relata uso eventual de álcool. Já para as variáveis “uso de crack” e “uso de cocaína”, foram considerados os casos em que os indivíduos relataram usar ou já terem feito uso das drogas uma vez na vida..A partir de fatores, como “escolaridade” e “idade”, foram criadas variáveis para análises com base em categorias e valores específicos. Para a escolaridade, criou-se a variável dicotômica “ensino médio”, cujas categorias representam: (1) possuir até 8 anos de estudo; e (2) possuir mais de 8 anos de estudo . Para a idade, foram criadas duas categorias de faixa etária: (1) pessoas de 18 a 24 anos, consideradas jovens; e (2) pessoas acima de 24 anos. A distinção foi realizada levando em consideração os diversos trabalhos sobre o tema que indicam que jovens possuem menores chances de adesão ao TARVStudente comparações de proporções por meio do teste baseado na estatística qui-quadrado de Pearson ou teste exato deFisher.As características sociodemográficas e comportamentais dos pacientes foram apresentadas separadamente para homens e mulheres, assim como as frequências de eventos  registrados ao longo do seguimento. Comparações de médias foram realizadas por meio do teste t degeneralized estimating equations). Como fatores do estudo, analisamos: apresentação clínica, internação hospitalar, infecção oportunista e gestação (no caso das pacientes mulheres). Variáveis sociodemográficas e de comportamento  foram utilizadas como controle nos modelos.O modelo de regressão logística foi utilizado para avaliar as associações entre fatores clínicos, sociodemográficos e comportamentais e a adesão ao TARV. Para considerar as correlações entre diferentes consultas em um mesmo paciente, foi utilizada a abordagem de equações de estimação generalizadas  de adesão ao tratamento antirretroviral. O primeiro modelo considera apenas as exposições em estudo; o segundo inclui variáveis sociodemográficas de controle; e o terceiro acrescenta as variáveis de uso de drogas.Statistical Package for the Social Sciences(SPSS), versão 18, utilizando o nível de significância de 5%. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da Universidade Federal do Rio Grande do Sul (CEP/UFRGS) e os pesquisadores assinaram um termo de compromisso de uso dos dados.As análises foram executadas no softwareAs características sociodemográficas e comportamentais dos pacientes são apresentadas naAnalisando o uso de drogas lícitas e ilícitas, o histórico de uso de homens é maior do que o de mulheres: 32,6% dos homens e 12,4% das mulheres possuem histórico de abuso de álcool ; 22,6% dos homens e 12,8% das mulheres apresentam histórico de cocaína , e 14,4% dos homens possuem histórico de uso de crack, enquanto nas mulheres a proporção é de 10,5% .Foi expressivo o número de prontuários analisados que não continham informações referentes à categoria de exposição ao HIV dos pacientes: 39,6% entre os homens e 14,3% entre as mulheres. Cerca de 84,9% das mulheres da amostra adquiriram o HIV por meio de relações heterossexuais – o que representa quase a totalidade das pacientes mulheres com a informação disponível. Nos homens, além da grande proporção de prontuários sem informação, 38,9% dos pacientes relataram infecção através de relações heterossexuais; 17,8% através de relações homossexuais e 3,7% devido ao uso de drogas injetáveis .Quanto à situação conjugal, as proporções se apresentaram semelhantes entre homens e mulheres: 51,9% deles e 45,7% delas eram solteiros(as), enquanto 29,1% dos homens e 32,7% das mulheres eram casadas(os) ou moravam junto com o parceiro. Já a variável escolaridade mostra que a maioria dos participantes da amostra possuem de 5 a 8 anos de estudo e que a proporção de pessoas com até 4 anos de estudo foi de 14,4% para os homens e 16,3% para as mulheres. As variáveis escolaridade e situação conjugal não apresentaram diferença estatisticamente significativa entre os grupos.AANo modelo 2, com variáveis sociodemográficas, estar assintomático  e sem registro de hospitalização  permaneceram aumentando as chances de adesão dos homens, embora a segunda variável tenha perdido significância estatística. Neste modelo, pacientes com mais de 8 anos de estudo têm aumento nas chances de adesão . Já no modelo 3, somente apresentação clínica permaneceu significativa, aumentando as chances de adesão em cerca de 43% na ausência de sintomas . Com relação ao uso de drogas, nunca ter usado crack aparece como fator associado à aderência .AAdicionando as variáveis sociodemográficas, o modelo 2 permanece com resultados semelhantes ao anterior, no qual a gestação  aumenta as chances de aderência em quase três vezes. A variável idade também apresenta associação, aumentando as chances em pessoas acima de 24 anos . Por último, no modelo 3, as pacientes em gestação na consulta apresentam mais que o triplo de chance de adesão , enquanto não ser jovem , e não usar cocaína  aumentam significativamente as chances de aderir.. No entanto, não são apenas características sociodemográficas que podem impactar na aderência ao tratamento, uma vez que eventos pontuais que ocorrem ao longo da vida dos pacientes também podem influenciar nessas chances. Entre estes eventos, destacamos: ocorrência de uma gestação; hospitalização; infecção por doença oportunista; e apresentação clínica.Diversos estudos apontam fatores sociodemográficos e de comportamento que podem influenciar nas chances dos pacientes aderirem ao TARV. Em muitos destes trabalhos, a adesão é tratada de forma “definitiva” e pouco flexível: o indivíduo é aderente, ou não é.Neste estudo, mulheres em gestação apresentam até 3,28 de chance de adesão ao TARV em comparação às mulheres que não estão gestantes. A literatura aponta que a gravidez pode impactar na adesão porque: (1) muitas mulheres iniciam o tratamento juntamente ao pré-natal, em que parte descobre sua sorologia para o HIV; (2) há uma atenção das políticas para essa população, focadas principalmente na atenção materno-infantil; (3) existem sentimentos e medos, por parte da gestante, de transmitir o HIV para o filho. Em contrapartida, diversos trabalhos apontam que, após o parto, aumentam as chances de falhas na adesão ou até mesmo abandono do tratamento.De fato, diversos são os incentivos empregados no âmbito do pré-natal para estimular a adesão ao TARV, por exemplo: maior atenção das equipes de saúde com as gestantes; rigor no acompanhamento das pacientes para evitar transmissão vertical do HIV; busca ativa de gestantes que não comparecem aos serviços de saúde etc. Dessa maneira, é esperado que esses incentivos estimulem um aumento na adesão durante a gravidez. Em outra análise dos dados da Coorte de Alvorada, evidenciou-se que as mulheres gestantes demoram menos tempo para atingirem carga viral indetectável para o HIV se comparado com as pacientes não gestantesIsso indica que a gestação pode ser um evento pontual que impacta positivamente na aderência ao tratamento justamente por conta da maneira como essa população é monitorada no período do pré-natal, em que recebem mais atenção das políticas de saúde e maiores estímulos para a construção do vínculo com os serviços de saúde. Após o término da gestação, no entanto, esses estímulos são enfraquecidos..O resultado deste estudo contribui para o entendimento do efeito da gestação na vida das mulheres vivendo com HIV e é relevante principalmente analisando a incidência de diagnósticos de HIV em gestantes no país e na região metropolitana que Alvorada está inserida. No Brasil, a taxa de detecção do HIV em gestantes cresceu 38,1% nos últimos 10 anos. Entre as capitais brasileiras, Porto Alegre registrou a maior taxa de detecção de HIV em gestantes no país, em 2018.Estas análises sugerem que os homens da amostra buscam manter a correta adesão, mesmo quando não possuem complicações do HIV, diferente de outros estudos com doenças crônicas que demonstram que a ausência de sintomas faz os pacientes deixarem de usar a medicação devido à falta de compreensão a respeito do curso da doença ou por julgarem que não é mais necessário o uso dos medicamentos.Contudo, esse resultado também pode ser analisado através da relação direta entre a adesão ao TARV e a esperada melhora sintomática dos pacientes, uma vez que a efetividade do tratamento e a ausência de sintomas dependem diretamente da adesão. Estudos mostram que para garantir supressão viral e uma redução significativa no risco de morte é preciso que os pacientes tomem corretamente pelo menos 95% da medicação prescrita. Por outro lado, apresentar sintomas também pode fazer com que o paciente opte por abandonar o tratamento por julgar que a piora sintomática possui relação com os medicamentos.Analisando a relação da apresentação clínica e da aderência na literatura, trabalhos mostram que a ausência de sintomas pode ser razão para aderir aos medicamentos, embora a melhora sintomática esteja, em alguns casos, associada ao abandono do tratamento, uma vez que o paciente pode julgar que não precise mais da medicaçãoe possibilidade de escolha diária em usá-los ou não é comum em tratamentos longos como de doenças crônicas. Após o desenvolvimento da terapia antirretroviral, a aids passou por uma transformação sobre o seu aspecto de doença aguda para crônica. Isto é, se antes a doença estava associada à certeza de morte, hoje é possível viver com o vírus do HIV cotidianamente. Assim como para outras doenças crônicas, a adesão regular do paciente ao tratamento pode não ocorrer mesmo com sintomas da doença. Ela também é dificultada porque, em alguns casos, pacientes não encaram o tratamento como sendo um processo longo e contínuo, característico de doenças crônicas.Esse tipo de “autogestão” dos medicamentos. Além das dificuldades em aderir, dados recentes têm mostrado que jovens são um dos grupos que mais tiveram aumento nas taxas de detecção de HIV nos últimos anos, evidenciando a vulnerabilidade dessas pessoas no cenário atual da epidemia. Entre os jovens na faixa etária de 20 a 24 anos, a taxa de detecção cresceu 94,6% na última década.Entre as variáveis sociodemográficas e comportamentais, foi encontrada associação entre idade e adesão ao TARV, onde possuir mais de 24 anos aumenta a chance de aderi-lo em até 82% entre as mulheres. Diversos são os estudos que investigam fatores associados à adesão ao TARV e apontam que pessoas jovens possuem menos chance de adesão tanto para o tratamento antirretroviral como para outras doenças crônicas. Uma ampla revisão da literatura desenvolvida sobre o tema mostra que são relatados diversos casos em que o uso de substâncias aparece associado a complicações do HIV, uma vez que reduzem as chances de adesão dos pacientes ao tratamento antirretroviral. Neste estudo, verificou-se que não possuir histórico de uso de crack e cocaína aumenta significativamente as chances de adesão. Outras pesquisas têm demonstrado que o uso de drogas tem efeito negativo sobre as chances de aderir, tanto em homens quanto mulheres e em países ricos ou pobres. Trabalhos e revisões envolvendo o uso de TARV também apontam que pessoas em uso de drogas apresentam maiores dificuldades em adesão, mesmo com presença de sintomas e quadros clínicos evoluídos à aids.Já o uso de drogas como crack e cocaína é apontado na literatura diversas vezes, também, como sendo um fator de grande impacto no TARV.É preciso ressaltar que, diferente de outros trabalhos, nossa amostra foi composta por consultas, o que pode estar relacionado à alta adesão encontrada no estudo . Espera-se que os pacientes que compareçam às consultas estejam mais propensos a seguir o tratamento, enquanto pessoas em adesão irregular tendem a faltar mais vezes ou até interrompem o tratamento, fazendo a proporção de consultas com pacientes em adesão na amostra aumentar naturalmente. Além disso, é preciso destacar que 1.170 consultas  foram excluídas das análises porque os pacientes não compareceram à ela. Por fim, outro fator que pode estar impactando essa proporção elevada de consultas em adesão é a própria maneira como a variável foi aferida. Em alguns casos, o autorrelato dos pacientes pode ser superestimado devido à preocupação em não desapontar os profissionais de saúde que prestam o atendimento. Além disso, o município apresenta escores menores que a média nacional em estatísticas da educação e desenvolvimento.A amostra do estudo contempla uma população em vulnerabilidade social. Mais da metade dos pacientes possuem até oito anos de estudo, o que equivale ao ensino fundamental, e aproximadamente um quarto possuem histórico de uso de crack e/ou cocaína. Alvorada está situada na Região Metropolitana de Porto Alegre e é o 2º município com menor PIB per capita do Rio Grande do Sul.Este estudo utilizou dados secundários, o que limita a análise dos dados somente para informações registradas nos prontuários. Nesse sentido, não foram exploradas outras características associadas à adesão que aparecem discutidas na literatura. Além disso, entre as variáveis selecionadas para as análises, em muitas consultas não foram encontradas as informações, reduzindo significativamente o número de unidades de análise da amostra. Também é importante reiterar que a maneira como a adesão foi aferida pode influenciar os resultados, uma vez que os pacientes podem referir maior aderência aos profissionais de saúde para não decepcioná-losPor outro lado, a grande contribuição do estudo é olhar a adesão na trajetória dos pacientes. Essa perspectiva permitiu demonstrar como alguns eventos pontuais que ocorrem na trajetória de pacientes em situação de vulnerabilidade podem impactar na adesão ao tratamento. A influência da gestação sobre a aderência sugere que o pré-natal possui importância para o tratamento de gestantes vivendo com HIV. No entanto, assim como a gestação, o período do pré-natal é passageiro, e não contempla todas as mulheres.Nesse sentido, novas estratégias que estimulem uma adesão permanente merecem ser pensadas para a garantia do sucesso terapêutico. Sobretudo, no caso das mulheres, é crucial a mudança de estratégias e implementação de políticas públicas que dão suporte às mulheres também após a gestação, quando a chance de adesão é reduzida. Além de fomentar o bem-estar das pacientes, medidas para o fortalecimento da retenção de mulheres puérperas aos serviços de saúde  precisam ser estimuladas, também, para o controle do risco de transmissão vertical por aleitamento, muitas vezes negligenciado pelas políticas de saúde.Os resultados do trabalho apontam que uma boa apresentação clínica aumenta as chances de adesão ao TARV para homens da amostra. Neste sentido, nossos dados indicam a importância da integração das estratégias de prevenção e assistência ao HIV, visto que pacientes com boa adesão tendem a ter carga viral indetectável, diminuindo significativamente as chances de transmissão do vírus.


The care of patients with HIV in the intensive care unit (ICU) can be complex as they may develop acute kidney injury and therefore necessitating continuous renal replacement therapy, need feeding tubes, and are prescribed new medications. Issues regarding drug-drug interactions, fluctuating renal & hepatic function, adverse effects, oral administration issues including crushing of tablets are challenges that may arise. The purpose of this study was to evaluate the appropriateness of antiretroviral (ARV) therapy in the ICU.Background - HIV and ICUsIn 2018, almost half of Americans living with HIV were aged 50 and older. Co-morbidities associated with ICU admissions include cardiovascular, renal, hepatic, and pulmonary disease. Medication errors are defined as: incorrect/incomplete regimen, incorrect dose, incorrect renal adjustment, incorrect administration, and major drug-drug interaction.This was a retrospective, observational, quality improvement project that reviewed charts from January 2018 to August 2022. Adult patients that were admitted to the the ICU at Long Island Jewish Medical Center and receiving ART for HIV were included. Patients receiving ARV for indications other than HIV were excluded. Using the medical record system, data was collected: demographics, renal and hepatic dysfunction, ARV ordered , completeness of treatment regimen, drug-drug interactions, feeding placement, and concomitant medications. Descriptive statistics were utilized.Of the 68 patients screened, 43 were included in the study. The mean age was 57 ± 13 years, 60.5% males, and majority of patients were admitted to the medical ICU (55.8%). The median CD4 count was 250 cells/μL and 37.2% of the patients had undetectable viral loads. A total of 18 patients (41.9%) required a gastric tube during their ICU stay. ID was consulted in 41.9% of the cases. Inappropriate ART was found in 46.5% of patients with drug-drug interactions, inappropriate tablet crushing, and renal dose adjustment needed being the most prevalent reasons for inappropriateness. 27 patients (62.8%) had opportunities for interventions. which included failure to re-initiate ARV sooner (n = 8), inappropriate ARV crushing (n = 8), ARV use contraindicated at time prescribed (n = 6), ARV not reconciled once stable (n = 5), and drug-drug interactions (n = 4). An intervention could have been made 5 days sooner on average.20 patients identified with an inappropriate ART regimen and patients could have had more than one reason for inappropriateness so total 26 identified reasons for inappropriate ART Most reasons for inappropriateness were related to patient’s renal function, ART administration, and drug-drug interactions followed by incomplete regimen. The other reason for inappropriateness was that patient was not re-initiated on ART during ICU stay when it was appropriate to do so.27 patients identified with one or more areas for improvement– these were interventions that could have been made. Most areas for improvement included earlier ARV re-initiation either to the same regimen from home PTA or a more appropriate regimen (such as a kidney or liver-sparring regimen) Other areas identified included inappropriate formulation/administration of ART, contraindications such as AKI were present at the time ART was ordered, addressing drug-drug interactions, Other = address drug-drug interactions (4), earlier initiation of new ARV regimen (patient was tx-naïve) (1), earlier initiation of adjusted ARV regimen (1), incomplete regimen (1)The study demonstrates that there are opportunities for improvement in the care of HIV in the ICU setting. Daily assessments of ART for re-initiation, dose adjustment, appropriate administration is crucial.All Authors: No reported disclosures


Isoniazid preventive therapy (IPT) is given to HIV patients to reduce the risk of active tuberculosis (TB). However, treatment completion remains suboptimal among those that are initiated. This study aimed to determine the completion level of IPT and the factors associated with non-completion among patients on antiretroviral therapy (ART) at Kisenyi Health Center IV in Kampala, Uganda.A mixed-methods facility-based retrospective cohort study utilizing routinely collected data from 341 randomly selected HIV patients initiated on IPT was conducted. Data extracted from the registers was used to determine IPT completion. Robust Poisson regression was conducted to determine the associated factors of IPT non-completion, while in-depth interviews were conducted to explore barriers to IPT completion from the patient’s perspective.A total of 341 patients who started on isoniazid (INH) were retrospectively followed up, with 69% (236/341) being female. Overall IPT completion was 83%. Multivariate analysis revealed the prevalence of IPT non-completion among males was 2.24 times the prevalence among females . The prevalence of IPT non-completion among patients with a non-suppressed HIV viral load was 3.00 times the prevalence among those with a suppressed HIV viral load . The prevalence of IPT non-completion among patients who were married, or cohabiting was 0.31 times the prevalence among those who were single . Lack of IPT-related health education, pill burden, distance to the health facility, and patient relocation were reported as barriers to IPT completion.IPT completion was found to be 83% among the cohort studied. However, lower completion levels persist among males and HIV-virally non-suppressed patients. Lack of IPT-related health education, pill burden, distance to the health facility, and patient relocation were reported as barriers to IPT completion. Interventions that target these groups of people need to be intensified. The World Health Organization (WHO) estimates a quarter of the world’s population to be infected with latent tuberculosis . An estiUganda had an estimated 1.4 million PLHIV in 2018, of whom 72% were on ART . Uganda WHO recommends the use of the three I’s (isoniazid preventive therapy (IPT), intensified case finding, and infection control) to reduce the risk and burden of TB in people living with HIV . IPT useIn 2014, Uganda adopted WHO guidelines that recommended the use of IPT for TB prevention as part of the comprehensive HIV/AIDS care strategy . DespiteIn addition, adherence and completion of treatment among patients initiated on IPT remain major concerns, as these affect its effectiveness . LimitedHowever, few studies have documented patient reasons for failure to complete the treatment in Uganda. Understanding this was key to improving the use of IPT among ART patients. Using routinely collected data, this study aimed to assess the completion of IPT and factors associated with non-completion among patients on ART. This would inform stakeholders on IPT completion, improve IPT use, and help realize its benefits, thereby reducing the risk and burden of active TB among these people.To determine the level of IPT completion and the factors associated with non-completion among people on antiretroviral therapy at Kisenyi Health Center (HC) IV in Kampala.To determine the level of IPT completion among people on antiretroviral therapy at Kisenyi Health Center IV in Kampala.To determine the factors associated with IPT non-completion among patients on antiretroviral therapy at Kisenyi Health Center IV in Kampala.To explore the barriers to IPT completion among ART patients from a patient’s perspective at Kisenyi Health Center IV.This was a mixed-methods facility-based retrospective cohort study utilizing routinely collected data. Quantitative data extracted from the facility registers was used to answer the questions on the completion of IPT and the factors associated with non-completion, while qualitative data collected through in-depth interviews with patients was used to explore the barriers to IPT completion from the patients’ perspective.Kampala, Uganda’s capital, has an estimated resident population of 1.5 million people . The stuThe study participants were HIV patients on ART at Kisenyi HC IV who had been initiated on IPT. To reduce recall bias, a total of 1166 ART patients who had been initiated on IPT in September 2019 at Kisenyi HC IV were considered.Only ART patients initiated on IPT in September 2019 were included in the study.Purposively selected non-completing ART patients for in-depth interviews who provided informed consent were also included in the study.ART patients initiated on IPT in any period other than September 2019 were excluded from the study, as were those whose records could not be traced or found at the facility.Patients who were ill and unavailable at the time of data collection and those who had no phone contact were excluded from in-depth interviews.IPT non-completion, which was measured as a person failing to pick up their fifth consecutive monthly refill within 6 months of initiation, was the dependent variable. On the other hand, IPT completion was defined as a patient picking up their fifth INH refill within 6 months of initiation.Patients who had begun IPT had to return to the health facility every month for five months, starting after a 2-week assessment for any self-reported adverse effects. IPT refills were given by clinicians at the monthly visit, and they also evaluated the patient’s adherence by pill count. INH was prescribed for multiple months to patients who received ART on a multi-month dispensation. Data on completion was extracted from the IPT registers, patient ART cards, and Uganda electronic medical records (UgandaEMR) system.The independent variables included age, sex, weight, height, body mass index (BMI), marital status, WHO HIV clinical stage at IPT initiation, and pre-IPT HIV viral suppression (defined as the most recent measurement within 12 months of IPT initiation). A patient was considered HIV-virally suppressed if they had a result of fewer than 1000 viral copies per milliliter of blood . Data onData collection ran for one month between November and December 2020. Quantitative data were extracted from the IPT register, ART cards, and the Uganda Electronic Medical Records System (EMR) using a structured data tool. Variables captured quantitatively were residence , WHO HIV stage at the time of IPT initiation, IPT refill and next appointment dates, weight (in kilograms), height (in centimeters), age (completed years), sex , body mass index , marital status, and pre-IPT viral load result. In-depth interviews that lasted 20–30 minutes were conducted by a trained research assistant with the help of an interview guide. Variables explored qualitatively included IPT-related health education, challenges encountered while on IPT, and smoking and/or alcohol consumption. These variables gave rise to some of the themes presented in the findings. All qualitative interviews were recorded with a call recording application and notes taken during the interviews. Interviews were conducted until saturation was reached.Potential bias at the participant selection stage was addressed by employing simple random sampling. The selection of respondents for in-depth interviews was also stratified. Recall bias among in-depth interview (IDI) respondents was minimized as the interviews were conducted within 9 months after the expected completion date.To determine the completion of IPT and the factors associated with non-completion, the Yamane formula at a 0.05 level of precision was used . This fo2]n = 1166/ [1+1166 (0.05) n = 298Adjusting for a 10% loss to follow-upThe minimum sample size required was 331.A list of IDs of patients initiated on IPT during September 2019 was compiled. Simple random sampling was used to select the 347 patients using Microsoft Excel. Their records were then extracted from the IPT registers into the data abstraction tool. The entry, cleaning, and sorting of data were all parts of the data management process. The data was entered into a specially designed Excel data screen. The data was then thoroughly examined for completeness and logical flow. Participants with missing variables were excluded from the data analysis.The characteristics of the study participants were described through descriptive analysis. Additionally, among those who started IPT, the percentage of participants who got their fifth consecutive monthly refill within 6 months was determined.Simple Poisson regressions of the outcome and the predictor were run to determine factors associated with non-completion to be included in the multivariate model. Variables with a p-value less than 0.2 were considered statistically significant for inclusion in multivariate analysis.A robust Poisson regression model was run to determine the predictors of IPT non-completion. The study had a binary outcome but used a robust Poisson model instead of logistic regression, which would have been suitable if the prevalence of IPT non-completion was under 10%. The use of logistic regression that gives odds ratios tends to overestimate the strength of association in such scenarios . VariablAll audio recordings were simultaneously transcribed and translated into English verbatim. Transcripts were then proofread for accuracy by the principal investigator (PI) before being uploaded to Atlas.ti Version 6.0 for analysis. Both inductive and deductive coding approaches were applied to generate the codebook ,29. The The research assistants were trained on how to ensure privacy and confidentiality for all participants both during and after data collection. Data collection took place at the height of the COVID-19 pandemic. Consequentially, in-depth interviews were conducted over the phone in place of physical interviews, and recorded consent was also obtained from the respondents for infection prevention and control (IPC) reasons. The respondent was asked to confirm their clinic number. The interview was then assigned a unique identifier for the proceeding transcription and analysis processes. Ethical approval for this study was sought and granted before the study by the Makerere University School of Public Health Higher Degrees, Research, and Ethics Committee. Permissions were subsequently granted by the director of public health environment at Kampala Capital City Authority (KCCA) and the in-charge Kisenyi HC IV.A total of 341 records of participants were included in the analysis. About  of the participants were aged 29 years and below. The median age was 33 (IQR 28–40). Most of the respondents were female  and  had a normal body weight. Additionally,  of the participants were at WHO HIV clinical stage 1. All the participants had a viral load test done in the last 12 months, with  having a suppressed result. Regarding marital status,  of the participants were married or cohabiting while  were divorced or separated .Of the 341 patients who started INH,  completed the dose, compared to  who did not. Among female patients,  of those who initiated IPT completed it, whereas  did not. Among males,  completed IPT, while  did not. Among patients with a suppressed HIV viral load,  completed IPT while  did not. Among patients with a non-suppressed HIV viral load,  did not complete IPT, compared to  who did. IPT was successfully completed by  of patients who were under the age of 30, compared to  who did not. About  of the patients who were married or cohabitated completed IPT, compared to  who did not.Factors associated with IPT non-completion, both at bivariate and multivariate analysis are presented in The prevalence of IPT non-completion among patients aged 30 years was 0.77 times the prevalence among those aged 29 years and below . The prevalence of IPT non-completion among males was 1.83 times the prevalence among females . The prevalence of IPT non-completion among patients with a non-suppressed HIV viral load was 3.46 times the prevalence among those with a suppressed HIV viral load . The prevalence of IPT non-completion among patients who were married, or cohabiting was 0.30 times the prevalence among those who were single .In multivariate analysis, factors significantly associated with IPT non-completion were sex, HIV viral suppression, and marital status. The prevalence of IPT non-completion among males was 2.24 times the prevalence among females . The prevalence of IPT non-completion among patients with a non-suppressed HIV viral load was 3.00 times the prevalence among those with a suppressed HIV viral load . The prevalence of IPT non-completion among patients who were married, or cohabiting was 0.31 times the prevalence among those who were single .The themes and subthemes that emerged were.Theme: knowledge about IPT.Theme: Challenges encountered while taking IPT. Subthemes: lack of transport, distance to the health facility, pill burden, and relocation.One of the reasons for noncompliance was the absence of IPT-related health education. The respondent was unaware of his IPT initiation.“…I met a friend at the garage where I work who disclosed that he was on drugs and had not received IPT all his life. So, I wondered why I had been given these tablets, yet the doctor didn’t tell me I had TB, I swallowed them for 2 months and got tired and stopped”single male patient.A high pill burden was another reason for IPT non-completion. This was more pronounced among patients who had to take other drugs for other pre-existing conditions, such as hypertension, in addition to ART and IPT.the tablets to swallow are very many, I have these ART tablets, then my hypertension tablets, and then the IPT. So, at times I’d forget to swallow the IPT as it wasn’t treating me for anything, and I completely stopped after forgetting it thrice”“…Female Patient.The distance to the health facility was cited as a challenge, as some of the patients could not afford transport fares every month to the health facility to pick up their IPT doses.the first challenge, most of us come from far and at the beginning they first gave me for a month and most of my work I am casually employed. So sometimes it would be hard for me to tell my boss there is somewhere I am going I will not be around now”“…Male Patient.A change of business and relocation from one place to another were cited as other reasons for IPT non-completion.when I shifted from Kisenyi to Kitebi, I didn’t go with my card and when I went to get my drugs from Kitebi, they didn’t give me IPT yet in Kisenyi they had given me for three months. I explained to the doctors, but they told me they’d give me next time until I got fed up and returned to Kisenyi where they have again started me on IPT again”“…Female patient.The goal of the study was to ascertain the IPT completion rate and related variables among those receiving antiretroviral therapy at Kisenyi Health Center IV in Kampala. The cohort of patients under study had an IPT completion rate of 83%, which was a comparatively high rate. This result is comparable to research from Zimbabwe and India, where studies ,31 indicThe higher completion level found by our study can be attributed to the efforts of the national Quality Improvement (QI) collaborative, which was founded in January 2019 to improve IPT completion as part of a wider continuous quality improvement effort in Uganda. All 14 of Uganda’s health regions, 126 of its 127 districts, and 739 ART-accredited sites were included in the collaborative. A situational analysis of IPT completion at high-volume health facilities was done as part of the QI collaborative, and these facilities received coaching support. Regional coaches worked with district-based coaches to help facility teams identify the causes of poor IPT completion, identify interventions, and create action plans to improve IPT completion. As a result of coaching help, facilities were able to develop local strategies to increase IPT completion while also testing approaches from other sites .Most patients receiving INH concurrently with ART lowers the expense of obtaining medication because they would not need to make as many trips to the medical institution, which contributed to the relatively high completion rate. Even though this study indicated that IPT completion rates have increased over time, 17% of patients who began IPT did not finish the treatment course. If IPT is not completed, its effectiveness is reduced, and the patient is once again in danger of developing active TB, which raises morbidity and mortality.Males were shown to have a higher prevalence of IPT non-completion than females. This finding is consistent with a study conducted in rural Malawi by Little et al., which found that males were more likely than females to fail to complete the study ; the typThe study also found that patients who had a non-suppressed HIV viral load had a higher prevalence of IPT non-completion. HIV viral non-suppression has been reported to be associated with, among other factors, adherence, defined as a patient’s ability to follow a treatment plan, take medications at prescribed times and frequencies, and follow restrictions regarding food and other medications . PatientAdditionally, the study found that marriage was strongly associated with a lower rate of IPT non-completion than being single. Married individuals are more likely to be open about their status with their partners , which oThis can also be explained by the fact that marriage gives patients stability by allowing them to be taken care of while undergoing therapy. IPT completion rates are expected to increase if these patients’ wives provide them meals on time and remind them to take their medications. This finding highlights the importance of providing ART patients, as well as those on IPT, with social support networks. These patients can benefit from social and psychological support from services like psychosocial and adherence counseling as part of the HIV care program .Patient-related barriers to IPT completion were explored in this study.To improve health-related patient literacy, knowledge and life skills that support individual and communal health need to be shared with patients. Numerous studies have shown that health education can enhance the effectiveness of patient care ,44. On tSome of the respondents abandoned IPT due to the pill burden. This finding is similar to studies conducted in Kenya, Swaziland, Zimbabwe, and India, which found that pill burden was one of the reasons for IPT non-completion, especially for patients who had to take other drugs for underlying conditions in addition to ART ,49–52. CThis was also cited as one of the barriers to IPT completion, as patients had difficulty accessing IPT doses due to a lack of transportation. This echoes findings from studies conducted in Tanzania, Zimbabwe, and Ethiopia, which found that patients were discouraged by the need to attend clinic every month combined with the long treatment duration of IPT ,54,55. AWhen patients relocate to new areas within or outside of Kampala, they also transfer to new, nearby health facilities. Most of these patients transfer to these sites without proper referral documentation, in what is termed “self-transfer” . In thisThe study’s limitations were mainly related to missing and incomplete data since this was a retrospective record review of routinely collected program data. This was overcome by triangulating data from different sources, i.e., the IPT, ART registers, ART cards, and the UgandaEMR.The study was conducted in one health facility in Kampala city, and hence the findings may not be generalizable to other health facilities within other cities and districts in Uganda. Treatment completion was assessed by a patient picking up a refill as a proxy for actual consumption of isoniazid. It is, however, possible that patients might have returned to pick up another refill without having consumed all the tablets from the previous refill.The study also explored barriers to IPT completion from the patient’s perspective and did not look at provider- or system-related barriers to IPT completion. To effectively improve IPT use, barriers to its completion from the provider’s perspective also need to be explored.Some of the planned interviews by stratification were not conducted as there were no patients or respondents in those strata. The barriers to IPT completion presented represent the patient categories that were interviewed.The barriers to IPT completion explored may have been limited by social desirability bias. This was mitigated by employing unconditional positive regard .Health caregivers or health workers need to provide patients with IPT-related health education before IPT initiation. Opportunities to give group health education on clinic days can be leveraged. Patient attitudes towards the therapy and, consequently, completion levels are likely to improve when patients are fully aware of why they are being initiated on the treatment.There’s a need for the Ministry of Health and partners to increase availability and access to other regimens of IPT with less frequent dosages compared to a 6- to 9-month daily dose of INH. This will reduce the pill burden, especially for patients with comorbidities, and improve adherence and completion rates.Health workers and health caregivers should provide and intensify treatment adherence support and counseling to HIV patients who are virally non-suppressed, not only for ART but also for IPT.There’s a need for the Ministry of Health to explore the use of biometric systems and link ART or TB clinics across health facilities to enable patients, especially the mobile populations, to access ART and IPT at any accredited health facility with accurate and timely documentation.Health facilities should take advantage of community DSD models and exploit them to deliver IPT in addition to ART and other related medications to eligible patients. Additionally, multi-month ART refills synchronized with IPT should also be taken advantage of to improve uptake and completion of IPT.There’s a need for further research on factors influencing IPT completion from the health system’s and provider’s perspectives.The IPT completion level was found to be relatively high, at 83% among the cohort of patients, but still less than the expected 95%. This corresponds with a general improvement in HIV services and the monitoring of HIV services by health facilities and stakeholders. Being male and being HIV-virally unsuppressed were significantly associated with a higher prevalence of IPT non-completion. Being married was associated with a lower prevalence of IPT non-completion. Lack of health education, pill burden, distance to the health facility, and relocation were reported as the reasons for failure to complete IPT.


Unsuppressed viremia in HIV infected patients is generally associated with increased rates of disease transmission and poor patient survival. This study assessed the socio-demographic determinants of People Living with HIV/AIDS, having viral load non-suppression and who are receiving antiretroviral therapy in a District Hospital in Ghana.p value of < 0.05 was considered statistically significant.The study utilized the cross-sectional research design with both primary and secondary data conducted from September to October 2021 in Ghana. Data were collected from 331 PLHIV who were placed on Anti-Retroviral Therapy (ART) for more than 12 months at the ART centre at a District Hospital in Ghana. Unsuppressed viremia was defined as plasma viral load of ≥ 1000 copies/mL after 12 months on an ART with effective adherent support. A structured questionnaire was used to collect primary data on participants and a Secondary data was also collected from patients’ folders, hospital registers and the computerized health information systems at the study site. SPSS was used to analyse descriptive and inferential data. Pearson’s chi-square and Fisher’s exact test were used to assess the independent determinants of viral load non-suppression. Pearson’s chi-square test was used for tests giving ≤ 20% of expected cell counts less than five while Fisher’s exact test was used for tests giving > 20% of expected cell counts less than five. A p = 0.03), income (p = 0.02), employment (p = 0.04), means of transportation (p = 0.02), cost of transportation to the ART centre (p = 0.03) and level of medication adherence (p = 0.02) as determinants of viral load non-suppression.Out of the 331 PLHIV who participated in the study, 174 (53%) were female and 157 (47%) were Male. The study found viral load non-suppression of 19% with age (There was a low level of viral load non-suppression among PLHIV after 12 months of active antiretroviral therapy with age, income, employment, means of transportation, cost of transportation and level of medication adherence influencing viral non-suppression. Thus, ART drugs and services should be decentralized to the community health workers’ level within the various localities of patients to decrease the economic consequences involved in accessing health care for PLHIV/AIDS. This will minimize defaulting, improve adherence and promote viral load suppression. Global HIV Statistics in 2019, estimated the burden of Human Immunodeficiency Virus (HIV) infection to be 37.9 (32.7 million – 44.0 million) million people who are living with the virus. There are 36.2 (31.3 million – 42.0 million) million adults and 1.7 (1.4 million – 2.3 Million) million children (< 15 years) who are currently living with the HIV pandemic globally, with 25.6 (22.2 – 29.5 million) million of the total burden living in Sub-Saharan Africa (SSA) [The USAID 95-95-95 target to end AIDS states that by 2030, 95% of people living with HIV know their HIV status, 95% of people living with HIV and who know their HIV status are on antiretroviral therapy and 95% of people who are on antiretroviral therapy have suppressed viral loads . This haThe essence of ART is to suppress the replication of HIV to the barest minimal level, halt the development of drug resistance viruses, restore and improve patient’s immunity, combat HIV/AIDS-related events and enhance the life span of the HIV-infected individual –8. SucceThe Ghana AIDS Commission has estimated that about 43% of patients on ART have achieved viral load suppression as of 2019 and there are a number of factors leading to viral non-suppression among patients on ART including; being an adolescent, nutritional scarcity, income and other economic factors , 15. It A descriptive cross-sectional design using the quantitative approach was utilized to assess the determinants of viral non-suppression among 331 PLHIV who are on ART for over 12 months at the ART outpatient clinic at the District Government Hospital in the Adansi South District in Ghana.th February 2004 by a Legislative Instrument (LI 1752) through an Act of parliament , after being carved out of Adansi West District and Adansi East District Assemblies in the same year. The district capital, New Edubiase is about 92 km from Kumasi, the regional capital, along the Cape Coast – Kumasi trunk road. The total population of Adansi South District, according to 2021 Population and Housing Census is 85,200 with 42,552 males and 42,648 females [The study was conducted in the District Government Hospital located in the Adansi South District in Ashanti Region. It has an Accident & Emergency centre, Laboratory services centre, Eye Clinic, Pharmacy, Antenatal centre, Obstetrics/ Gynaecology services, Mental health, Hypertension and Diabetes centres, and Reproductive and Child health centres. The facility has a daily OPD attendance of over 150 and an annual attendance between 10,000 and 15,000. Adansi South District was created on 18ument LI 52 througThe Adansi South district was selected for the study because the district has been in the news in Ghana in terms of HIV/AIDS infection since 2005 with an HIV prevalence of 3.7% as at 2005 . As at 2The study population included all HIV-infected adults ≥ 18 years who had been on antiretroviral therapy and had attended the clinic at the selected study site in Adansi South from January 2018 to October 2021. The study included all PLHIVs who were 18 years and above and have been on ARTs for 12 months and above at the selected ART clinic at the study site. Data from the District Hospital showed that 3 out of 329 PLHIV who initiated ART in 2018 died, two out of 469 PLHIV receiving ART died in 2019, four out of 502 PLHIV receiving ART died in 2020 and six out of 615 PLHIV on ART died in 2021. Thus, a population of 1900 was used in the sample size calculation.Yamane’s formula for calculating sample size was used to determine the total sample size as stated below:N = population under studye = margin of error (0.05)Thus,At 20% non-response rate = 66.2Sample size = 398, however due to resource constraints, a final sample size of 331 was used for the study.A total of 331 folders of patients who satisfied the inclusion criteria were sampled. 331 PLHIV participated in the study. For this study it was assumed that PLHIV are well aware of viral loads and its importance thus, they will be willing to discuss this subject to help draw conclusion to identify determinants of viral load non-suppression.The variable gender in this study refers to male or female and was measured according to the participants’ choice on the questionnaire. Marital status considers the current status of the participant in terms of intimate relationship with a spouse or prospective partner, termination of this relationship or the demise of a partner. Marital status was measured by participants’ choice of responses as itemised on the questionnaire. A person is considered married when customary rites have been performed according to Ghana laws or a law court has registered their marriage. Again, ‘divorced’ means separation by law while ‘separated’ was considered as one spouse walking away from marriage. ‘Widowed’ was considered as the demise of a spouse. ‘Single’ status was considered for persons not involved in any intimate relationship while cohabiting refers to persons living together as partners in the absence of legal or customary marriage. There were three categories of religion based on the system in Ghana. Christians are those known to believe in Jesus Christ and worship in churches while Muslims are those who believe in Muhammed and worship in mosques. Traditionalists are those who worship smaller gods in shrines. These were self-reported.Educational status was categorised into five groups. Those without formal education included participants who had never enrolled into any kind of educational centre registered with the Ghana Education Service. Primary denotes those who had attained basic education and JHS status involves persons who enrolled or have taken the Basic Education Certificate Examination. SHS status was assigned to those who enrolled or had taken the West African Senior School Certificate Examination while tertiary status involved those enrolled in an accredited university or training college. These were all self-reported. Employed status include those who have gained positions or roles in government or private companies to perform assigned duties. Those involved in personal business were also considered employed. Those without jobs whether in the government or public sector or personal business including students were considered unemployed. Age means the length of time a person has lived on earth. Monthly income, means of transport and cost of travelling to ART centre were self-reported. Transport by bus included those with private cars or motors and those who joined public buses, motors or tricycles to their destination. While those on foot included participants who walked to the ART centres.Patients with plasma viral load of ≥ 1000 copies/mL after 12 months on an ART with effective adherent support were considered as viral non-suppressed, those with plasma viral load of < 1000 copies/mL after being on ART as viral suppressed and patients with plasma viral load of < 400 copies/mL after being on ART were considered as undetectable. Participants were grouped into good adherence and poor adherence. Good adherence referred to strict compliance or not missing pills in their history while poor adherence referred to non-compliance or missing pills sometimes or often in their history.A random sampling method was employed in this study. Outpatients who met the inclusion criteria were asked to select Yes or No labelled pieces of papers randomly from a concealed box. Those who picked yes were included in the study. The process was repeated until the sample size of 331 had been achieved. Those who picked yes were taken through detailed information session on the study, their questions were answered, and they were taken through informed consent form signing.An approval letter was sought from the District Government Hospital in the Adansi South District in Ghana. Permission was sought from the Unit in charge at the ART centre, thereafter patients were approached, and the purpose of the study was explained to them. Patients who consented to the study were given the questionnaire to fill. A structured questionnaire was used in collecting data on independent variables such as sex, age, marital status, religion, educational status, occupation, monthly income, means of transport, cost of travelling to ART centre, duration on ART to determine the socio-demographic characteristics of participants. Data on viral loads of participants were recorded as the dependent variable of this study. All variables were self-reported with the exception of viral loads which were recorded from patients’ folders and records. Upon their consent, primary data were collected from the patients on monthly income, means and cost of transportation to ART centre as well as time to reach the ART Centre were obtained from the consented patients with a questionnaire. Afterwards, Secondary data was collected from the patients’ folders, hospital registers and the computerized health information systems at the study site. The tool collected data on the socio-demographic as well as clinical data of the patients to meet the study objectives. Three nurses who served as research assistants were trained to collect the data over a period of 28 days between September to October 2021. Viral loads of PLHIV were obtained by collecting and labelling blood samples and transporting to the largest referral hospital in the Region, Komfo Anokye Teaching Hospital for analysis.Data was encrypted and stored on a secure cloud storage which is in line with Ghana’s Data Protection Act subsection 24. Soft copy data was backed up on an encrypted online storage to avoid data loss. At the end of data collection, data was transferred into Microsoft excel and encrypted for added security. The Microsoft excel file was only available on a password protected computer accessible to the research team. Hard copies of filled questionnaire were sealed in an envelope and kept under lock and key in a locker in the principal researcher’s office. Data quality assurance was done by double entry of results by two different people for validation. Both hard copy data and online data were merged after data entry. The data was cleaned to correct mistakes, assess missing data and determine appropriate methods for resolving challenges including follow-ups. All methods were carried out in accordance with relevant guidelines.Data were analysed using a statistical package for social sciences (SPSS) version 20. Descriptive statistics: frequencies were used to describe demographic and socioeconomic related characteristics of the participants. The data were presented using tables, flow charts, pie charts, diagrams, and graphs among others to communicate effectively. Pearson’s chi-square and Fisher’s exact test were used to test the association between selected independent variables and unsuppressed viremia as the dependent variable. Test statistics with a p-value of < 0.05 were considered statistically significant.A total of three hundred and thirty-one (331) Secondary data of HIV patients who were on ART and met the inclusion criteria were retrieved from the ART Centre and used for the analysis.One hundred and seventy-four (53%) of the participants were females. Age distribution was even across the groups. Most of the participants (64%) were married, with 42 13%) of them separated and two (7%) widowed. For the religious affiliation of the participants, most of them were from the Christian faith 223 (67.4%). With regards to educational attainment, 49 (15%) did not have any formal education, 175 (52.8%) had up to primary education and 19 (5.7%) schooled to the tertiary level. Economically, the findings indicated that 277 (83.7%) were employed and 54 (16.3%) were not employed. Majority 185 (55.9%) of participants earned less than 200 cedis ($25) per month with a few numbers eight (2.4%) of the participants earning more than 1500 cedis ($193) per month. Most 236 (71.3%) respondents took the bus to the facility with about 22 (6.6%) walking to the facility for treatment. One hundred and fourteen (34.4%) of participants spent less than 10 cedis ($1.29) as cost for travelling to the centre while about 79 (23.9%) spent over 50 cedis ($6.45) to travel to the centre as shown in Table 3% of thep = 0.331), marital status (p = 0.169), religious affiliation (p = 0.223), educational level (p = 0.184). However, there was a direct statistically significant difference between age (p = 0.013), employment status (p = 0.022), income (p = 0.011) and means of transportation (how patients travel from their community to the ART centre) (p = 0.040), cost of travel to the ART centre (p = 0.017) and level of medication adherence (p < 0.001) and viral load non-suppression as shown in Table Results from Pearson’s chi-square and Fisher’s exact test showed that there was no statistically significant difference between viral load non-suppression and sex p = 0.33, maritalThe findings from the study as indicated below in Fig. The study assessed the number of PLHIV/AIDS who are on ART and are viral load non-suppressed, as well as the determinants of viral load non-suppression among PLHIV/AIDS on active anti-retroviral therapy in Adansi South District, Ghana. We found that 19% of patients at the outpatient unit of the AIDS centre had viral load suppression. Pearson’s chi-square and Fisher’s exact test showed that employment, age, income, means of transportation and cost of travel to centre for ART was significantly associated with viral load suppression.The study revealed that most of the PLHIV were females as compared to the male population. The finding is in agreement with global data that women contribute the highest to the total population of PLHIV currently . Most imVirological failure among PLHIV is associated with the presence of comorbidities like active tuberculosis, mental conditions, high level of pre-treatment HIV RNA, and late initiation of ART , 23, 24.Barriers to achieving the UNAIDS 2020 strategic target of 90% undetected viremia continues to pose a great deal of challenge to the success of the set goal, especially in the low-and-middle-income countries such as in Sub-Saharan Africa. Individual factors such as age, religion, educational status, adherence, and socioeconomic factors like poverty, not being married, stigmatization and disclosure continue to be a barrier to undetected viremia as indicated in the report by WHO (2016). A strong relationship between linkage and retention to care by PLHIV remains the hope of achieving undetected viremia in the HIV/AIDS continuum of care . This cuThe study revealed that age as a demographic factor of the PLHIV on the ART was the main factor that influence’s viral non-suppression. Various available studies support the fact that age has a significant impact on viral non-suppression , 27. Youp = 0.02), employment (0.04), means of transportation (p = 0.02), and cost of transportation to the ART centre (p = 0.03). These findings support the assertion that the individual's economic status has a more significant impact on HIV infection and the success of adherence and attainment of viral suppression [The study found that the major determinants of viral load non-suppression were socio-economic issues comprising; income  which identified level of medication adherence as a major factor contributing to viral non-suppression. The study by Afrane et al. (2021) was a cross-sectional study which included 250 children from the age of eight months to 15 years old. Despite the association of viral load non-suppression and level of medical adherence, it was recommended by the Ghana Health Service through the National AIDS control programme (2016), that individuals presenting with viral loads > 1000 copies/ml should undergo a strict ART adherence with monthly viral load test for three months to determine whether high viral load titres is due to poor adherence or treatment failure. Thus, viral load non-suppression in persons with good medication adherence could help identify treatment failure . A compaThe study was conducted in the Adansi South District in the Ashanti Region of Ghana with a population of less than 10% of the whole country’s population, therefore, generalizability should be done with caution. The cross-sectional study design used in this study is not as robust as a study design such as a cohort study or case–control study where two groups of participants could have been followed over a period prospectively for factors contributing to viral load non-suppression. Since some parts of the data were self-reported by the participants, there is the possibility of recall bias affecting the accuracy of the data collected. That notwithstanding, our study has revealed that factors such as income, cost of transportation and level of medication adherence influence viral non-suppression. This could be the basis for ART drugs and services’ decentralization to community health workers’ level within the various localities of patients to decrease the economic consequences involved in accessing health care for PLHIV/AIDS. This will minimize defaulting, improve adherence and promote viral load suppression in PLHIV/AIDS.It is recommended that future studies should focus on the use of a larger sample drawn from other regions and districts of the country to ensure generalizability of study findings. Future studies should consider a more robust study design such as cohort or case–control to improve the efficiency and accuracy of the study since possible bias and confounders can be well controlled. ART drugs and services should be decentralized to the community health workers’ level within the various localities of patients to decrease the economic consequences involved in accessing health care for PLHIV/AIDS. This will minimize defaulting, improve adherence and promote viral load suppression.There was a low level of viral non-suppression among PLHIV after 12 months of active antiretroviral therapy with age, income, employment, means of transportation, cost of transportation and level of medication adherence influencing viral non-suppression. A review of ART services to ensure availability at the community level will also promote viral load suppression.