ABSTRACT

Adherence to treatment is one of the major challenges to HIV (Human Immunodeficiency Virus) treatment, being depression a factor that impacts on it. The research aimed to identify if depression interferes with adhesion. A multi-approach method for adherence, open interview and Beck Depression Inventory were used for depression screening. The relationship between depression and nonadherence was not found, although the prevalence of depression reached 22.24%. Some patients assume fear of stigma and difficulty in following antiretroviral treatment due to the drug adverse effects. Also a social protection network was perceived as crucial as was the necessity to build a care network.

KEYWORDS
HIV; Medication adherence; Depression; Primary Health Care; Social support

Introduction

The Acquired Immunodeficiency Syndrome (Aids) is an advanced clinical manifestation of the disease caused by the Virus of Human Immunodeficiency (HIV). Its distinguishing trait is a disturbance of cellular immunity resulting in higher susceptibility to opportunistic infections and neoplasias ¹1 Brasil. Ministério da Saúde. O Manejo da Infecção pelo HIV na Atenção Básica: Manual para Profissionais Médicos [internet]. Brasília, DF: Ministério da Saúde; 2015 [acesso em 2016 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/anexos/publicacao/2016/58663/manejo_da_infeccao_manual_para_medicos_pdf_17112.pdf.
http://www.aids.gov.br/sites/default/fil... . The transmission of this syndrome is predominantly sexual, in spite of there being other forms of exposure to HIV such as blood and vertical transmission ¹1 Brasil. Ministério da Saúde. O Manejo da Infecção pelo HIV na Atenção Básica: Manual para Profissionais Médicos [internet]. Brasília, DF: Ministério da Saúde; 2015 [acesso em 2016 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/anexos/publicacao/2016/58663/manejo_da_infeccao_manual_para_medicos_pdf_17112.pdf.
http://www.aids.gov.br/sites/default/fil... .

In Brazil, there were, in 2015, 830.000 people living with the HIV, and there were 32.321 new notifications of infection by HIV in that year ²2 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Bol Epidemiol. 2017; 48(1):1-51 [acesso em 2017 set 4]. Disponível em: http://portalarquivos.saude.gov.br/images/pdf/2017/janeiro/05/2016_034-Aids_publicacao.pdf.
http://portalarquivos.saude.gov.br/image... .

Since 1996, according to Law # 9.313/96, the Brazilian government guarantees the distribution of antiretroviral drugs in the environment of the Unified Health System (SUS), being the first developing country to adopt a public policy of access to Antiretroviral Therapy known as ART ³3 Brasil. Ministério da Saúde. Adesão ao tratamento antirretroviral no Brasil: coletânea de estudos do projeto ATAR [internet]. Brasília, DF: Ministério da Saúde; 2010 [acesso em 2015 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/atar-web.pdf.
http://www.aids.gov.br/sites/default/fil... . In 2013, a new approach to stopping the Aids epidemics became possible by means of the decision to treat every person living with the HIV, regardless of what their CD4 count could reveal about their immune state, making primary care centers responsible for treatment and for increasing the coverage of HIV testing among key populations ⁴4 Brasil. Programa Conjunto das Nações Unidas sobre HIV/Aids. Taxas de prevalência de Aids em populações-chave. c2018. [acesso em 2017 set 4]. Disponível em: http://unaids.org.br/wp-content/uploads/2015/06/pop-chave-prev-02.jpg.
http://unaids.org.br/wp-content/uploads/... .

This access to ART assured by the Brazilian government and by international initiatives in the same sense made possible the improvement in survival and quality of life rates of patients, leading to the understanding of Aids as a chronic disease. Yet the use of antiretroviral drugs (ARVs) also came along with significant side effects, which led to an adherence problem. In this context, matters related to adopting standards to promote adherence to the services and to ART became not only a priority but required a continuous and long lasting focus ⁵5 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Manual de adesão ao tratamento para pessoas vivendo com HIV e AIDS. Brasília, DF: Ministério da Saúde; 2008 [acesso em 2015 jul 9]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_adesao_tratamento_hiv.pdf.
http://bvsms.saude.gov.br/bvs/publicacoe... .

The HIV positive patient who abandons a drug therapy or follows it incorrectly can make room for opportunistic infections. Therefore, adherence to treatment ends up having quite evident social and political implications, both in terms of the investment made by the Brazilian government and in terms of controlling the epidemics ⁵5 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Manual de adesão ao tratamento para pessoas vivendo com HIV e AIDS. Brasília, DF: Ministério da Saúde; 2008 [acesso em 2015 jul 9]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_adesao_tratamento_hiv.pdf.
http://bvsms.saude.gov.br/bvs/publicacoe... . Recent studies stress the need for policies aiming at tackling the epidemics to improve quality of care and promote adherence to therapy ³3 Brasil. Ministério da Saúde. Adesão ao tratamento antirretroviral no Brasil: coletânea de estudos do projeto ATAR [internet]. Brasília, DF: Ministério da Saúde; 2010 [acesso em 2015 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/atar-web.pdf.
http://www.aids.gov.br/sites/default/fil... . From the viewpoint of public health, non-adherence is both an individual and collective threat ⁵5 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Manual de adesão ao tratamento para pessoas vivendo com HIV e AIDS. Brasília, DF: Ministério da Saúde; 2008 [acesso em 2015 jul 9]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_adesao_tratamento_hiv.pdf.
http://bvsms.saude.gov.br/bvs/publicacoe... .

The combination of two or more adherence methods is necessary for purposes of monitoring, but none of the methods presents enough accuracy to define the real situation regarding the use of medication ⁶6 Polejack L, Seidl EMF. Monitoramento e avaliação da adesão ao tratamento antirretroviral para HIV/Aids: desafios e possibilidades. Ciênc Saúde Colet [internet]. 2010 Jun [acesso em 2018 fev 9]; 15(suppl1):1201-1208. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232010000700029&lng=en.
http://www.scielo.br/scielo.php?script=s... .

In spite of the knowledge that the viral load is subject to the influence of clinical complications, vaccines and drug interaction ⁷7 Günthard HF, Saag MS, Benson CA, et al. Antiretroviral Drugs for Treatment and Prevention of HIV infection in adults. JAMA. 2016; 316(2):191-210., the only measurement good for assuring that the patient is actually taking the ARV is that of gauging the presence of the medication in the bloodstream ⁸8 Llabre MM, Weaver KE, Durán RE, et al. A Measurement Model of Medication Adherence to Highly Active Antiretroviral Therapy and Its Relation to Viral Load in HIV-Positive Adults. AIDS Patient Care STDS. 2006 Out; 20(10):701-711.. That is why the quantification of HIV in the bloodstream, also known as Viral Load (VL), is used for monitoring the response to the antiretroviral treatment and for early detection of virological failure ¹1 Brasil. Ministério da Saúde. O Manejo da Infecção pelo HIV na Atenção Básica: Manual para Profissionais Médicos [internet]. Brasília, DF: Ministério da Saúde; 2015 [acesso em 2016 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/anexos/publicacao/2016/58663/manejo_da_infeccao_manual_para_medicos_pdf_17112.pdf.
http://www.aids.gov.br/sites/default/fil... .

Self-reporting has been the most used method for monitoring adherence both in research and in daily healthcare ⁶6 Polejack L, Seidl EMF. Monitoramento e avaliação da adesão ao tratamento antirretroviral para HIV/Aids: desafios e possibilidades. Ciênc Saúde Colet [internet]. 2010 Jun [acesso em 2018 fev 9]; 15(suppl1):1201-1208. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232010000700029&lng=en.
http://www.scielo.br/scielo.php?script=s... . It is considered a low cost method that does not require much time, and allows to hear patients and solve problems related to the ingestion of the ARVs. However, there are also problems related to this method considering the differences between the adherence measurement methods and the tendency of patients to overestimate their behavior when under medication ⁶6 Polejack L, Seidl EMF. Monitoramento e avaliação da adesão ao tratamento antirretroviral para HIV/Aids: desafios e possibilidades. Ciênc Saúde Colet [internet]. 2010 Jun [acesso em 2018 fev 9]; 15(suppl1):1201-1208. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232010000700029&lng=en.
http://www.scielo.br/scielo.php?script=s... ^,99 Bonolo PF, Gomes RRFM, Guimarães MDC. Adesão à terapia anti-retroviral (HIV/Aids): fatores associados e medidas da adesão. Epidemiol Serv Saúde [internet]. 2007 Dez [acesso em 2018 fev 09]; 16(4):267-278. Disponível em: http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S1679-49742007000400005&lng=pt.
http://scielo.iec.gov.br/scielo.php?scri... .

Among the variables that interfere in the adherence to ART, depression is acknowledged for its capacity to lead to negative outcomes such as reduction in adherence to medication, in quality of life and possible worsening of disease progression and mortality ¹⁰10 Nanni MG, Caruso R, Mitchell AJ, et al. Depression in HIV Infected Patients: A Review. Curr Psychiatry Rep. 2015 jan; 17(1):530.. Depression is knowingly a pathology presenting a high level of improvement when treated, and this improvement can reduce unnecessary use of healthcare centers, bring down mortality and extend patient survival ¹¹11 Pinto DS, Mann CG, Wainberg M, et al. Sexuality, vulnerability to HIV, and mental health: an ethnographic study of psychiatric institutions. Cad. Saúde Pública [internet]. 2007 Set [acesso em 2018 fev 9]; 23(9):2224-2233. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2007000900030&lng=en.
http://www.scielo.br/scielo.php?script=s... .

Depression is the psychiatric disturbance prevalent among HIV infected individuals ¹²12 Gonzalez JS, Batchelder AW, Psaros C, et al. Depression and HIV/AIDS Treatment Nonadherence: A Review and Meta-Analysis. J Acquir Immune Defic Syndr. 2011 Out; 58(2):181-187.. Although there are studies considering a variation in the prevalence of depression among People Living with HIV/Aids (PLHA) ranging from 0% to 42%, the consensus is that it is most frequent among this group than among the population in general, the difference being of 30% on one side and of 11% on the other, respectively ¹²12 Gonzalez JS, Batchelder AW, Psaros C, et al. Depression and HIV/AIDS Treatment Nonadherence: A Review and Meta-Analysis. J Acquir Immune Defic Syndr. 2011 Out; 58(2):181-187..

Thus, this study aimed at analyzing adherence to treatment among HIV positive patients, identifying patients diagnosed with depression and verifying the interruption of ART due to depression symptomatology.

Methodology

The study took place at the Germano Sinval Faria School Health Center (CSEGSF) of the Oswaldo Cruz Foundation, in Rio de Janeiro in the year of 2016, a choice made for its accumulated experience in the assistance to HIV positive patients in the environment of primary care since 1999.

This work made use of the mixed investigation method, characterized by the combined use of qualitative and quantitative investigation, as we understand it to be more adequate for analyzing the complex phenomena inherent to social and health sciences ¹³13 Creswell JW. Projeto de pesquisa: métodos qualitativo, quantitativo e misto. Porto Alegre: Artmed; 2010.^,1414 Greene JC. Is Mixed Methods Social Inquiry a Distinctive Methodology? J Mix Methods Res. 2008 Jan; 2(1):7-22..

The phases of the research followed the identification of patients who began the ART program in 2014, the revision of the medical history of those patients and the implementation of the Beck Depression Inventory, as well as of a semi-structured interview process.

The criteria for inclusion encompassed cases of HIV/Aids among individuals of 18 years of age and above who started the ART program in the period between January and December 2014 at the CSEGSF, where their reference doctor worked, and who accounted for two levels of viral load when beginning treatment.

For identification of patients, the System for Logistical Control of Medication (Siclom) of the Pharmacy Service was useful. Physicians were in charge of recruiting their patients for the study during their appointments there.

Once the patient was identified, a revision of his medical records was made in order to find his socio-demographic information, the date of his HIV/Aids diagnosis, and the viral load measured from his beginning at the ART program up until March 30 2016. There was tracing of any information related to complications that could lead to interrupting or changing treatment. Attention was paid to depression diagnosis, usage of alcohol and drugs or to any account of a prior follow-up of patient by mental health professionals, even more so in the case of a correlated drug prescription.

Interviews were performed according to the availability of patients. At first, patients answered the Beck Depression Inventory II (BDI II). Semi-structured interviews were conducted with the purpose of finding out how they came to know they were ill; the impact of the disease in their life; how the treatment began, how it felt to follow the ART program, and whether depression interfered somehow in the ingestion of medication.

Developed by Beck et al. ¹⁵15 Paranhos ME, Argimon IIL, Werlang BSG. Propriedades psicométricas do Inventário de Depressão de Beck-II (BDI-II) em adolescentes. Aval Psicol [internet]. 2010 Dez [acesso em 2018 fev 9]; 9(3):383-392. Disponível em: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1677-04712010000300005&lng=pt.
http://pepsic.bvsalud.org/scielo.php?scr... , the BDI II consists of a self-reporting instrument made of 21 questions encompassing items related to depression symptomatology. This instrument is regularly used in polls and studies on depression among HIV/Aids patients.

For adherence measurements, the choice was made for a multi-approach method⁶6 Polejack L, Seidl EMF. Monitoramento e avaliação da adesão ao tratamento antirretroviral para HIV/Aids: desafios e possibilidades. Ciênc Saúde Colet [internet]. 2010 Jun [acesso em 2018 fev 9]; 15(suppl1):1201-1208. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232010000700029&lng=en.
http://www.scielo.br/scielo.php?script=s... ^,88 Llabre MM, Weaver KE, Durán RE, et al. A Measurement Model of Medication Adherence to Highly Active Antiretroviral Therapy and Its Relation to Viral Load in HIV-Positive Adults. AIDS Patient Care STDS. 2006 Out; 20(10):701-711.^,99 Bonolo PF, Gomes RRFM, Guimarães MDC. Adesão à terapia anti-retroviral (HIV/Aids): fatores associados e medidas da adesão. Epidemiol Serv Saúde [internet]. 2007 Dez [acesso em 2018 fev 09]; 16(4):267-278. Disponível em: http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S1679-49742007000400005&lng=pt.
http://scielo.iec.gov.br/scielo.php?scri... combining the self-reporting of the interviews and the objective measurements provided by the viral load records and the System for Logistical Control of Medication (Siclon) for removal of ARVs.

The first adherence measurement made for the purpose of this study was the percentage of days on ARV medication. An adopted standard of adherence was the ingestion of 95% of the prescribed doses, being this the same standard adopted by the Ministry of Health (MH). The Siclom data, based on the dates of removal of medication and on the number of tablets prescribed, allowed seeing how regularly medication would be taken from the pharmacy and whether patients had enough medication for fulfilling or not the adherence standard established by the MH.

The percentage of days on medication was calculated according to the following equation: total of days on medication divided by the follow-up time. For the purpose of calculating the days encompassed by the follow-up time, March 30 2016 was taken as a reference date and was subtracted from the date in 2014 when the patient registered at the Siclom.

In that sense, all patients who remained 95% or more of their time on medication, according to the follow-up information, were considered adherent to the ART program.

The second method, that of the viral load count, considered adherent every patient who attained viral suppression up until 24 weeks from the beginning of the ART program. Suppression is understood as a viral load with a maximum of 50 copies/ml of blood ⁷7 Günthard HF, Saag MS, Benson CA, et al. Antiretroviral Drugs for Treatment and Prevention of HIV infection in adults. JAMA. 2016; 316(2):191-210..

Self-reporting, the third adherence criterion, to be verified during the interview, identified as an adherent patient anyone who informed having made the correct use of the ARV medication as prescribed.

This research had the approval of CAEE: 52415216.7.0000.5240.

Results and discussion

Chart 1 shows the number of subjects in each phase of the study, along with the analysis of losses and variables.

Among the 34 initial patients, six were ruled out for different reasons: one for death; two for assistance by physicians of other institutions; a homeless patient for assistance by another health center, another one for no count of viral load; and yet another one was transferred to another unit. The loss of ten subjects during the interview was due to refusal. Nine possible participants, who the professionals had contacted by phone, were impossible to find when the study actually began.

Among patients analyzed, there were 15 men and 13 women. The predominant age bracket included individuals between 20 and 49 years of age, representing 78,57%. Among the total, 92,86% were of a middle school educational level. Because of a lack of reliable records related to employment and income, it was not possible to identify the profession or the occupation of two of the subjects.

The health policy advocates that a partition per territory, through which patients access services within their respective programmatic areas, is not possible of enforcement in what refers to HIV/Aids. The patient in need of ART can refer to another primary care unit to obtain the necessary drug therapy yet not to the specialized services ¹1 Brasil. Ministério da Saúde. O Manejo da Infecção pelo HIV na Atenção Básica: Manual para Profissionais Médicos [internet]. Brasília, DF: Ministério da Saúde; 2015 [acesso em 2016 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/anexos/publicacao/2016/58663/manejo_da_infeccao_manual_para_medicos_pdf_17112.pdf.
http://www.aids.gov.br/sites/default/fil... . Furthermore, matters related to prejudice and to fear of identification can be responsible for the migration towards other services.

Table 1 shows data on comorbidity or on worsening factors that may interfere in the adherence process.

It is verified that 71.42% of patients deny making use of illegal substances, 28,56% declare such use and 10,71% report having used cocaine but being currently in abstinence. Regarding alcohol consumption, 67,85% of subjects report uses, a mark quite close to what the literature describes3.

In a large number of medical records, -89.28%, no mental health occurrence could be found, probably revealing not only patients not manifesting depression but also suggesting there could be insufficient diagnosis of mental disturbances16.

The research revealed that 50% of the subjects had an HIV diagnosis and initiated ART in 2014, whereas the other half, whose diagnosis came prior to 2014, probably began ARV treatment because of the implementation of Treatment as Prevention (TasP).

Since the advent of the combined Antiretroviral Treatment (ART), HIV infection has been regarded as a chronic disease. Therefore, once the ARV treatment begins there can be no more interruption due to the viral replication risk ⁵5 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Manual de adesão ao tratamento para pessoas vivendo com HIV e AIDS. Brasília, DF: Ministério da Saúde; 2008 [acesso em 2015 jul 9]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_adesao_tratamento_hiv.pdf.
http://bvsms.saude.gov.br/bvs/publicacoe... . As the time of medication usage increases up until the end of a lifetime, fatigue becomes a common and expected consequence resulting from daily use, complexity of schemes, different restrictions and social and even physical changes related to treatment. For that reason, an early adoption of ART is possibly a factor that may hinder adherence ¹⁴14 Greene JC. Is Mixed Methods Social Inquiry a Distinctive Methodology? J Mix Methods Res. 2008 Jan; 2(1):7-22..

On the other hand, a new presentation of the antiretroviral therapy, reducing the scheme to a single tablet, helps in the extended use of ARVs and acts as an adherence facilitator.

Table 2 shows the outcomes of adherence according to those three criteria. Self-reporting will be discussed in the interview session.

It was verified that, according to the dispensation of drugs standard, 60.74% of patients were considered adherent. The monitoring of ARV dispensation is important for the identification of patients with irregular removal of such drugs from the pharmacy ⁹9 Bonolo PF, Gomes RRFM, Guimarães MDC. Adesão à terapia anti-retroviral (HIV/Aids): fatores associados e medidas da adesão. Epidemiol Serv Saúde [internet]. 2007 Dez [acesso em 2018 fev 09]; 16(4):267-278. Disponível em: http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S1679-49742007000400005&lng=pt.
http://scielo.iec.gov.br/scielo.php?scri... , even though, as in other adherence methods, it might bring accuracy problems ⁸8 Llabre MM, Weaver KE, Durán RE, et al. A Measurement Model of Medication Adherence to Highly Active Antiretroviral Therapy and Its Relation to Viral Load in HIV-Positive Adults. AIDS Patient Care STDS. 2006 Out; 20(10):701-711.. Interpreting data on ARV dispensation suggests nothing else but adherence or non-adherence, given that being in possession of the medication is no assurance that it will be ingested regularly or ingested according to the prescription ⁶6 Polejack L, Seidl EMF. Monitoramento e avaliação da adesão ao tratamento antirretroviral para HIV/Aids: desafios e possibilidades. Ciênc Saúde Colet [internet]. 2010 Jun [acesso em 2018 fev 9]; 15(suppl1):1201-1208. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232010000700029&lng=en.
http://www.scielo.br/scielo.php?script=s... ^,88 Llabre MM, Weaver KE, Durán RE, et al. A Measurement Model of Medication Adherence to Highly Active Antiretroviral Therapy and Its Relation to Viral Load in HIV-Positive Adults. AIDS Patient Care STDS. 2006 Out; 20(10):701-711.^,99 Bonolo PF, Gomes RRFM, Guimarães MDC. Adesão à terapia anti-retroviral (HIV/Aids): fatores associados e medidas da adesão. Epidemiol Serv Saúde [internet]. 2007 Dez [acesso em 2018 fev 09]; 16(4):267-278. Disponível em: http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S1679-49742007000400005&lng=pt.
http://scielo.iec.gov.br/scielo.php?scri... .

According to viral load count, 71.42% of patients were adherent.

Viral load count is not ideal for gauging adherence, considering that several factors can influence such measurement, and 96% of patients remaining in treatment and receiving ARVs have non-traceable HIV levels in their bloodstream ⁷7 Günthard HF, Saag MS, Benson CA, et al. Antiretroviral Drugs for Treatment and Prevention of HIV infection in adults. JAMA. 2016; 316(2):191-210..

As for the third adherence standard, which is self-reporting, 55.55% of the interviewed subjects informed having made correct use of the ARVs.

As per official data ³3 Brasil. Ministério da Saúde. Adesão ao tratamento antirretroviral no Brasil: coletânea de estudos do projeto ATAR [internet]. Brasília, DF: Ministério da Saúde; 2010 [acesso em 2015 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/atar-web.pdf.
http://www.aids.gov.br/sites/default/fil... , the average rate of non-adherence is of 34.5%. However, there can either be large variability among values found or, depending on the type of measurement and on how to define adherence, confirmation of results.

The established percentage of adherence varies in accordance to the adherence metrics definition to be applied, be it self-reporting through interviewing, daily record, tablet count, medical record registry, pharmacy dispensation, electronic device, or a combination of methods, besides the study design itself ³3 Brasil. Ministério da Saúde. Adesão ao tratamento antirretroviral no Brasil: coletânea de estudos do projeto ATAR [internet]. Brasília, DF: Ministério da Saúde; 2010 [acesso em 2015 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/atar-web.pdf.
http://www.aids.gov.br/sites/default/fil... ^,77 Günthard HF, Saag MS, Benson CA, et al. Antiretroviral Drugs for Treatment and Prevention of HIV infection in adults. JAMA. 2016; 316(2):191-210.^,99 Bonolo PF, Gomes RRFM, Guimarães MDC. Adesão à terapia anti-retroviral (HIV/Aids): fatores associados e medidas da adesão. Epidemiol Serv Saúde [internet]. 2007 Dez [acesso em 2018 fev 09]; 16(4):267-278. Disponível em: http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S1679-49742007000400005&lng=pt.
http://scielo.iec.gov.br/scielo.php?scri... . The other important means for evaluating adherence is depression itself.

The analysis of the BDI instrument considered significant a depression whose results were above 21 points, corresponding to 22.23% of the subjects (table 3), which is quite close to the results of the systematic review and of the metanalysis ¹⁷17 Sin NL, DiMatteo MR. Depression Treatment Enhances Adherence to Antiretroviral Therapy: A Meta-Analysis. Ann Behav Med. 2014 Jun; 47(3):259-269.^,1818 Uthman OA, Magidson JF, Safren SA, et al. Depression and Adherence to Antiretroviral Therapy in Low-, Middle- and High-Income Countries: A Systematic Review and Meta-Analysis. Curr HIV/AIDS Rep. 2014 Sept; 11(3):291-307..

Data shown suggest a 22.23% prevalence of depression among the interviewed subjects ¹²12 Gonzalez JS, Batchelder AW, Psaros C, et al. Depression and HIV/AIDS Treatment Nonadherence: A Review and Meta-Analysis. J Acquir Immune Defic Syndr. 2011 Out; 58(2):181-187.^,1515 Paranhos ME, Argimon IIL, Werlang BSG. Propriedades psicométricas do Inventário de Depressão de Beck-II (BDI-II) em adolescentes. Aval Psicol [internet]. 2010 Dez [acesso em 2018 fev 9]; 9(3):383-392. Disponível em: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1677-04712010000300005&lng=pt.
http://pepsic.bvsalud.org/scielo.php?scr... ^,1616 Chiaverini DH, organizadora. Guia prático de matriciamento em saúde mental. Brasília, DF: Ministério da Saúde; 2011..

The study revealed that only 5.55% of the interviewed subjects with a high depression score acknowledged a relation between depression and ARV ingestion.

Patients adhering to treatment stop taking the medication as prescribed at some moment and, in spite of having experienced the discovery of HIV as something difficult to accept, eventually manage to rebuild their life by adapting to the new situation. However, non-adhering patients can only think about the deeply disturbing moment of discovering they have the disease. In that sense, it is possible that the 22% rate of depression prevalence indicates a group more prone to abandon treatment. As for the 55%, they continue to experience the disease as something deeply disturbing and this seems to be predominant among patients incapable to adhere ¹⁹19 Cardoso GP, Arruda A. As representações sociais da soropositividade e sua relação com a observância terapêutica. Ciênc Saúde Colet [internet]. 2005 Mar [acesso em 2018 fev 14]; 10(1):151-162. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232005000100022&lng=en.
http://www.scielo.br/scielo.php?script=s... .

The interviews made possible the acknowledgement of categories leading to an understanding of the experience of living with HIV/Aids and of the adherence to treatment based on psychosocial aspects that actively interfere in the process. Such categories are the discovery by the HIV bearer of his condition, the impact this has on his life, the experience with the antiretroviral therapy, and the protection network.

Discovering one bears HIV/Aids

The moment of receiving the diagnosis is critical considering the severity of the disease and how there can be an impairment prognosis, and it can unfold in ways important to the life of the individual, to his treatment and consequently to his adherence habits.

The care taken when communicating the diagnosis, and the interaction with the health professional, are critical at that moment, given that the emergence of helplessness feelings might affect the way patients use the message they receive from the professionals so as to define their life projects ³3 Brasil. Ministério da Saúde. Adesão ao tratamento antirretroviral no Brasil: coletânea de estudos do projeto ATAR [internet]. Brasília, DF: Ministério da Saúde; 2010 [acesso em 2015 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/atar-web.pdf.
http://www.aids.gov.br/sites/default/fil... .

Among 18 patients, only four of them received the contagion news from the CSEGSF professionals. Three of them became aware of their condition through the positive testing of their spouses. One came to know because of laboratory examination. All of them remain asymptomatic. The other 14 received the information from professionals of other health services, seven of which remained asymptomatic.

Surprisingly, for some receiving the diagnosis did not cause any unrest neither any significant impact: "It was normal... I already knew it" (P13).

The majority of the subjects demonstrated ambivalence between life and death when becoming aware that they were bearing the HIV/Aids. The anguish felt at that moment seems to relate to the possibility of death, partially because of the persistent understanding that Aids kills, partially because an important change will have to take place in order to live with the disease in an effective manner and with quality of life.

Five patients reported having found reasons to move on with life and look for treatment, showing resilience in spite of the pain felt when receiving the diagnosis:

A patient described how devastating receiving the HIV diagnosis was to him:

Results found by older studies regarding reactions to the diagnosis are similar, in spite of how significantly the treatment expectation and survival rates for people with HIV/Aids have improved ³3 Brasil. Ministério da Saúde. Adesão ao tratamento antirretroviral no Brasil: coletânea de estudos do projeto ATAR [internet]. Brasília, DF: Ministério da Saúde; 2010 [acesso em 2015 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/atar-web.pdf.
http://www.aids.gov.br/sites/default/fil... .

Emotional shock, concern with health condition, anxiety related to the appearance of symptoms, anguish, fear of dying, fear of being left alone by relatives and friends, anger, shame and guilt were among the reactions found³3 Brasil. Ministério da Saúde. Adesão ao tratamento antirretroviral no Brasil: coletânea de estudos do projeto ATAR [internet]. Brasília, DF: Ministério da Saúde; 2010 [acesso em 2015 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/atar-web.pdf.
http://www.aids.gov.br/sites/default/fil... .

Cardoso and Arruda¹⁹19 Cardoso GP, Arruda A. As representações sociais da soropositividade e sua relação com a observância terapêutica. Ciênc Saúde Colet [internet]. 2005 Mar [acesso em 2018 fev 14]; 10(1):151-162. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232005000100022&lng=en.
http://www.scielo.br/scielo.php?script=s... state that this moment of discovery is associated to death, yet it requires a new life condition, a one better adapted to the new situation.

Patients described finding in their children a reason to live and to engage in ART: "I had this desire to kill myself, but then I thought about my children... I was desperate... But I knew I didn't want to die ..." (P20).

Ayres²⁰20 Ayres JRCM. Cuidado e reconstrução das práticas de Saúde. Interface Comun Saúde Educ. [internet]. 2004 Fev [acesso em 2018 fev 9]; 8(14):73-92. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-32832004000100005&lng=en.
http://www.scielo.br/scielo.php?script=s... addresses care as a philosophical construct, a category to describe philosophical understanding and practical attitude, considering the meaning that health actions acquire in the several situations whenever there is a claim for therapeutic action and for interaction between one or more subjects aiming at finding relief to pain or some kind of well-being. Ultimately, taking care of others is taking care of oneself, and this is what is what becomes clear when the concern with his children leads to P20 taking care of himself.

A few subjects described the impact when receiving the diagnosis: "I got nervous at the moment. It had never occurred to me that I would have to bear something so serious" (P2).

Yet others experienced not only the impact of receiving the diagnosis but a feeling of discomfort that would not leave and could lead to depression: "I am not normal any longer as I have limitations. I am not any longer a person who can do certain types of things" (P11).

The concept of recovery seems to be important for the understanding of what these patients describe about the difficulty to find solutions to the discomfort that receiving the HIV diagnosis causes.

Recovery is defined as a process, a daily challenge and a return of hope, of personal confidence, of social participation and of a sense of having control over one's life that ends up taking place. It is not at all a matter of returning to the stage prior to the disease. On the contrary, it is about finding personal strength yet having the disease as a baseline, and finding new solutions to the adversities ²¹21 Carvalho SM, Paes GO. A influência da estigmatização social em pessoas vivendo com HIV/AIDS. Ciênc Saúde Colet. 2011; 19(2):157-163..

When receiving the diagnosis, it is inevitable that the interviewed subjects raise the question on the means of transmission and to have them mostly falling into the category of sexual HIV transmission.

In Brazil, 96.4% of registered cases among women, in 2012, derived from heterosexual intercourse with HIV infected partners. Among men, 36.8 % of cases resulted from heterosexual intercourse, 50.4% from homosexual intercourse and 9% from bisexual intercourse. The remainder of cases relate to blood and vertical transmission²2 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Bol Epidemiol. 2017; 48(1):1-51 [acesso em 2017 set 4]. Disponível em: http://portalarquivos.saude.gov.br/images/pdf/2017/janeiro/05/2016_034-Aids_publicacao.pdf.
http://portalarquivos.saude.gov.br/image... .

Among the interviewed subjects, 33% clearly stated that they had caught the disease from having sex with someone with whom they had an intimate relationship, like husband, wife, companion or sweetheart. Besides discovering that they had a severe and chronic disease, these people had to deal, against their will, with breaking of trust.

A patient described having been contaminated by her boyfriend, who kept it secret until he fell ill and was taken to the hospital: "I became aware that he had it. Later on, when I went to test myself, I found out I had it" (P7).

For a few patients, it is not worth to investigate the form of transmission:

Becoming aware of an HIV positive status because of sexual transmission also leads to feelings of anger and betrayal: "The way it was passed on to me was somehow coward" (P10).

The concepts of fidelity, stability, regular partner relation and monogamy provide a feeling of safety to those who put them into practice, which can lead to letting go of condoms during intercourse, but can also be partially responsible for a more devastating impact when receiving the diagnosis.

There were those who described failure in using the condom: "the condom ended up being torn when I was with my ex-boyfriend" (P19).

The refusal to believe in the diagnosis and the absence of reaction seem to relate more to denial of the disease than to unawareness of the HIV:

Impact over life

There are cases in which the diagnosis becomes a propeller for changes considered positive, relating to valuing oneself and life, to being optimistic and hopeful ³3 Brasil. Ministério da Saúde. Adesão ao tratamento antirretroviral no Brasil: coletânea de estudos do projeto ATAR [internet]. Brasília, DF: Ministério da Saúde; 2010 [acesso em 2015 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/atar-web.pdf.
http://www.aids.gov.br/sites/default/fil... . Living with the HIV can lead to a sense of sensitivity and solidarity. The concept of resilience relates to understanding the diagnosis yet allowing it to make room for change and for new opportunities in life ²¹21 Carvalho SM, Paes GO. A influência da estigmatização social em pessoas vivendo com HIV/AIDS. Ciênc Saúde Colet. 2011; 19(2):157-163..

The first identified impact relates to a positive change in life:

The resilient capacity to approach the disease and the treatment and to deal with the means of contagion and their consequences is decisive for adherence to treatment and for protecting against depression.

Another impact made evident relates to relationship break-ups and to fear of having a new relationship, which involves not only affection aspects as well as sexual ones.

Another person described the interruption of sex life:

This feeling of 'being blocked' from love and sex relationships after diagnosis is very common, even more so when it is understood that the means of contagion was sexual ³3 Brasil. Ministério da Saúde. Adesão ao tratamento antirretroviral no Brasil: coletânea de estudos do projeto ATAR [internet]. Brasília, DF: Ministério da Saúde; 2010 [acesso em 2015 jul 9]. Disponível em: http://www.aids.gov.br/sites/default/files/atar-web.pdf.
http://www.aids.gov.br/sites/default/fil... .

It was observed that psychological aspects or experiences related to sadness, depression or anxiety were significant. The findings regarding depression show that it might not relate directly to the HIV diagnosis, but rather to its consequences, not necessarily having an impact on the ingestion of medication:

A subject described quite precisely the relation between HIV and depression, most of all regarding relationships, as if it were not possible anymore to trust people:

There were accounts of depression of a more severe kind, where there was a willingness to die: "I wanted to die... I got so depressed that I would not feel hungry neither thirsty" (P20).

An important aspect is fear of the social stigma coming along with the disease, which modifies and restrains the lives of the ones involved and prevails in this study given its major impact:

The majority of the interviewed subjects keep the diagnosis to themselves due to this stigma. They either do not share it or share it only with those closest to them:

The fear of having revealed their HIV status led to the search of other health services: "I didn't want to be treated here, I wanted to be treated somewhere else... there are many people who are cruel to us, who are prejudiced" (P16).

According to Carvalho and Paes ²¹21 Carvalho SM, Paes GO. A influência da estigmatização social em pessoas vivendo com HIV/AIDS. Ciênc Saúde Colet. 2011; 19(2):157-163., the stigma and prejudice that remain associated to HIV and Aids contribute to the suffering experienced when receiving those diagnoses and are a reason for keeping the news secret. Sharing or not information and feelings related to diagnosis, treatment and prognosis is a decision that has an influence on family and social relations, on the adherence to treatment and on self-care ²²22 Pachankis JE. The psychological implications of concealing a stigma: a cognitive-affective-behavioral model. Psychol Bull. 2007; 133(2):328-345., as shown by Cardoso and Arruda ¹⁹19 Cardoso GP, Arruda A. As representações sociais da soropositividade e sua relação com a observância terapêutica. Ciênc Saúde Colet [internet]. 2005 Mar [acesso em 2018 fev 14]; 10(1):151-162. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232005000100022&lng=en.
http://www.scielo.br/scielo.php?script=s... .

Pachankis ²¹21 Carvalho SM, Paes GO. A influência da estigmatização social em pessoas vivendo com HIV/AIDS. Ciênc Saúde Colet. 2011; 19(2):157-163. discusses the differences between visible and invisible stigma and states that invisible stigma is cause of stress as it requires decision making on to whom to disclose, being this a source of anticipation anxiety related to the possibility of being discovered, isolated and excluded. "I didn't want to come here as I was ashamed of what society could say, not because of myself but because of my children" (P20).

Patients in the study corroborate the findings of Gomes et al. ²³23 Gomes AMT, Silva EMP, Oliveira DC. Representações sociais da AIDS para pessoas que vivem com HIV e suas interfaces cotidianas. Rev Latino-Am Enfermagem [internet]. 2011 Jun [acesso em 2018 fev 9]; 19(3):485-492. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692011000300006&lng=en.
http://www.scielo.br/scielo.php?script=s... given that they seem to have more fear of the social consequences of their condition than of the condition itself and the possibility of it getting worse. There is deep fear of 'social death', of rejection, resulting in dual suffering due to social implications overlapping physical ones.

Experience with the antiretroviral

The experience regarding the adverse effects of the ARVs was no different among those who were asymptomatic, and joined the ART only because of the change in the MH protocol, and the other patients.

There were accounts of people who did not feel the adverse effects: "The treatment itself was not bad... I didn't experience any discomfort, didn't feel sick..." (P12).

The beginning of treatment is the hardest period for adherence due to the inclusion of the drugs and their side effects into the daily routine ²⁴24 Rodrigues M, Maksud I. Abandono de tratamento: itinerários terapêuticos de pacientes com HIV/Aids. Saúde debate. 2017 Abr; 41(113):526-538., and because it mobilizes a field of representation related to being HIV positive ¹⁹19 Cardoso GP, Arruda A. As representações sociais da soropositividade e sua relação com a observância terapêutica. Ciênc Saúde Colet [internet]. 2005 Mar [acesso em 2018 fev 14]; 10(1):151-162. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232005000100022&lng=en.
http://www.scielo.br/scielo.php?script=s... .

In spite of the strong reactions caused by such drugs, the disappearance of symptoms in a few months is expected, with the system eventually adapting itself to the substances: "I felt awful, but I was aware that I was going through an adaptation period" (P19).

Several patients reported improvement regarding adverse effects, especially in the second year of treatment, which coincides not only with the time of ingestion of ARVs by the subjects but also with a change in the display of the drugs: "In the beginning of the second year it already felt much better" (P6).

The understanding of treatment continuation had to do with attending medical consultations, taking the prescribed tests and taking the ARVs: "If you follow it, you will be alright. I did what the doctors told me, and it was alright. I'm keeping on, I can't stop" (P16).

Two subjects considered abandoning the treatment. Four of them actually did abandon ART, yet only one subject linked the interruption of the ARV treatment to feelings related to depression.

All others denied even having thought about interrupting.

The improvement because of ART seems to have been acknowledged by the patients:

Part of the population of this study started the ARV therapy only because of the change in the HIV/Aids treatment protocol established by the MH, and was in good general condition, with no symptoms. That would be a reason why a few individuals did not acknowledge improvement through the medication treatment.

Protection network

In general, the intimate protection network provided the necessary social support in the form of spouses, friends, mother, father and companions. However, even within this familiar network, patients chose to whom they should disclose: "I told it only to my companion" (P19).

The presence of relatives and friends can be decisive for maintaining treatment as it helps in the daily routines, including those related to basic health care and the following up of the medication schedule ²²22 Pachankis JE. The psychological implications of concealing a stigma: a cognitive-affective-behavioral model. Psychol Bull. 2007; 133(2):328-345.: "My current husband supports me to the point that he reminds me that it is time to take the medicine. He asks me if I have already taken it" (P15).

Emotional support can be decisive both for the acceptance of treatment and for protecting from the risk of suicide. At the very moment of receiving the diagnosis, support from family or from someone playing that role seems to be important;

Social support, especially when provided by the family, is related to a reduction in psychological pain, in frequency of psychiatric symptoms, in rates of anxiety and depression and is connected to better quality of life as well ¹⁰10 Nanni MG, Caruso R, Mitchell AJ, et al. Depression in HIV Infected Patients: A Review. Curr Psychiatry Rep. 2015 jan; 17(1):530..

Patients go through a process of accepting the diagnosis, which influences how they will engage in the treatment and has an effect on the way family and social network can understand what is going on and position themselves accordingly.

There are certainly aspects beyond rationality at play in the treatment and in how to adhere to it, with a range of interference beyond PLHA.

Faith and belief provide a fundamental kind of social support ²⁵: "If not for God, I think I would have killed myself" (P14).

Religion contributes to building an understanding of the world and of life by means not only of its cosmology but also of its daily practices, therefore playing an important role in terms of providing social suppport²⁵ and corroborating the findings of this research:

Social support has a positive influence on the health status of people as it can be understood as an agent making possible better control over life. Therefore, it strongly helps in the confrontation of adversities and in sharing experiences based on exchange and mutual care, given that it benefits both the one receiving as well as the one providing support ²³23 Gomes AMT, Silva EMP, Oliveira DC. Representações sociais da AIDS para pessoas que vivem com HIV e suas interfaces cotidianas. Rev Latino-Am Enfermagem [internet]. 2011 Jun [acesso em 2018 fev 9]; 19(3):485-492. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692011000300006&lng=en.
http://www.scielo.br/scielo.php?script=s... ^,2424 Rodrigues M, Maksud I. Abandono de tratamento: itinerários terapêuticos de pacientes com HIV/Aids. Saúde debate. 2017 Abr; 41(113):526-538..

Conclusions

The combination of the three adherence standards established by the study, in spite of the variations amongst them, showed that 38.88% of the interviewed subjects were considered adherent. The viral load threshold reached by almost all patients is a sign of therapeutic success.

It is still a challenge to identify adequate and effective manners to measure adherence. In that sense, it is important to do more research and with a larger number of patients, especially by means of the yet timid utilization of the viral load standard, if one wants to test a good method to adhere to ART.

The duration of the study might have influenced the non-verification of depression as a variable with impact on treatment. Even if 22.24% of patients were found to be depressed, they seem to have adhered to ART. However, one must treat depression symptoms in order to avoid any worsening of the psychological condition to the extent of it affecting the quality of life of those individuals and the ingestion of antiretroviral medication.

It is essential that public healthcare service professionals pay attention to the aspects shown and that the health centers have available a multi-professional team. Training professionals is important for them to know the disease, the stigma, the treatment and the hindrances to adherence, even in the sense of stimulating the development of a network to protect and support patients and their relatives.

References

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History