ABSTRACT

The present study aimed to investigate the association between Common Mental Disorders (CMD) and viral load in People Living with Human Immunodeficiency Virus - HIV (PLHIV) in clinical follow-up. A cross-sectional study was performed with 307 PLHIV aged ≥ 18 years who were on antiretroviral therapy at the Specialized Care Service of the city of Santos (SP) in 2016. The dependent variable of the study was the quantification of viral load and the independent variable comprised the minor psychic disorders assessed by the Self-Reporting Questionnaire (SRQ-20). To compare the mean levels of the variables, generalized linear models were performed with significance level of 5%. It is concluded that CMD are associated with a higher viral load among PLHIV in clinical follow-up.

KEYWORDS
HIV-1; Viral load; Mental disorders

Introduction

Human Immunodeficiency Virus (HIV) is a retrovirus that infects and progressively destroys immune system cells, especially CD4 T lymphocytes. The reproduction of the virus leads infected cells to death, promoting the destruction of the architecture of lymphoid organs and the immune deficiency characteristic of the syndrome¹1 Abbas AK, Lichtman AH, Pillai S. Imunologia básica: funções e distúrbios do sistema imunológico. 5. ed. Rio de Janeiro: Elsevier; 2017..

By 2017, there was, in the world, a total of 36.9 million People Living with HIV (PLHIV). In Brazil, in the same year, there were 866 thousand PLHIV, which represented 2.3% of the worldwide prevalence. During the period, 42 thousand new infections were registered, and it is estimated that 11 thousand deaths related to the virus occurred in the Country, accounting for 42.0% of the diagnoses in Latin America²2 The Joint United Nations Programme on HIV/Aids. Miles to go: closing gaps, breaking barriers, rightning injustices. Ending Aids: Progress towards the 90-90-90 targets. Global Aids update 2018 [acesso em 2018 set 13]. Disponível em: http://www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdf.
http://www.unaids.org/sites/default/file... .

In the city of Santos (SP), which between 1980 and 2000 received the title of ‘Aids’ national capital’, at least five new cases of HIV are diagnosed per week³3 Etzel A, Silva NG, Lacerda R, et al. Cascata do cuidado contínuo em HIV/Aids em Santos-SP 2015. In: Anais do 31º Congresso de Secretários Municipais de Saúde do Estado de São Paulo; 2017 Mar; Santos. Santos: Secretaria Municipal de Saúde; 2017.. Although it is currently considered a reference in the fight against HIV with the STI/Aids and Hepatitis Program, the city is still in an epidemic situation. In December 2015, the municipality’s Specialized Care Service (SCS) had 5.522 users with HIV alive and registered in the system; of these, 4,717 (85%) were frequent in the assistance³3 Etzel A, Silva NG, Lacerda R, et al. Cascata do cuidado contínuo em HIV/Aids em Santos-SP 2015. In: Anais do 31º Congresso de Secretários Municipais de Saúde do Estado de São Paulo; 2017 Mar; Santos. Santos: Secretaria Municipal de Saúde; 2017..

With the advent of antiretroviral therapy (HAART), Acquired Immunodeficiency Syndrome (Aids) has gone from an acute disease to a chronic disease. With the control of viral replication, PLHIV have acquired a higher life expectancy and have had fewer opportunistic infections⁴4 Hankins C. Overview of the current state of the epidemic. Curr. HIV/AIDS rep. [internet]. 2013 [acesso em 2018 jul 30]; 10(2):113-123. Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/23579359.
https://www.ncbi.nlm.nih.gov/pubmed/2357... . Currently, Brazil has one of the largest coverage of HAART in the world, with 64.0% of people diagnosed receiving free treatment by the Unified Health System (SUS), regardless of their immunological status²2 The Joint United Nations Programme on HIV/Aids. Miles to go: closing gaps, breaking barriers, rightning injustices. Ending Aids: Progress towards the 90-90-90 targets. Global Aids update 2018 [acesso em 2018 set 13]. Disponível em: http://www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdf.
http://www.unaids.org/sites/default/file... .

In most individuals, immune reconstitution is observed shortly after the onset of HAART. In Brazil, in 2017, 85.0% of PLHIV aged 18 years or older who had been on HAART for at least six months had reached viral suppression. In the state of São Paulo, there were 88.0%⁵5 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Relatório de Monitoramento Clínico do HIV. Brasília, DF: MS; 2018.. However, in spite of the clinical improvement achieved by pharmacological treatment, PLHIV often report great emotional suffering that directly interferes with their health conditions and quality of life⁶6 Taibi DM, Price C, Voss J. A pilot study of sleep quality and rest-activity patterns in persons living with HIV. J. Assoc. Nurses AIDS Care [internet]. 2013 [acesso em 2018 jul 30]; 24(5):411-421. Disponível em: http://dx.doi.org/10.1016/j.jana.2012.08.001.
http://dx.doi.org/10.1016/j.jana.2012.08... .

Among the factors that promote such wear, the chronicity and severity of the disease, the adverse effects of HAART are emphasized, and the need to deal with complex, persistent and uncontrollable stressors⁷7 Segerstrom SC. Optimism and immunity: do positive thoughts always lead to positive effects? Brain Behav. Immun. [internet]. 2005 [acesso em 2018 jul 30]; 19(3):195-200. Disponível em: http://dx.doi.org/10.1016/j.bbi.2004.08.003.
http://dx.doi.org/10.1016/j.bbi.2004.08.... , such as discrimination and fear of becoming sick⁸8 Tunala LG. Daily sources of stress among HIV-positive women. Rev. saúde pública [internet]. 2002 [acesso em 2018 jul 30]; 36(4):24-31. Disponível em: http://dx.doi.org/10.1590/S0034-89102002000500005.
http://dx.doi.org/10.1590/S0034-89102002... .

According to the World Health Organization (WHO)⁹9 World Health Organization. Depression and other common mental disorders: Global health estimates. Geneva: WHO; 2017 [acesso em 2018 set 13]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf?sequence=1.
https://apps.who.int/iris/bitstream/hand... , Common Mental Disorders (CMD) comprise two main diagnostic categories: depressive disorders and anxious disorders. Symptoms influence the mood and feelings of those affected and differ in relation to their severity and duration.

In the 1970s, WHO conducted a study that aimed to validate low-cost methods for tracking CMD. From this study, the Self-Reporting Questionnaire (SRQ-20) has emerged, an instrument proposed by Harding¹⁰10 Harding TW, de Arango MV, Baltazar J, et al. Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries. Psychol Med. [internet]. 1980 [acesso em 2018 jul 30]; 10(2):231-241. Disponível em: http://dx.doi.org/10.1017/S0033291700043993.
http://dx.doi.org/10.1017/S0033291700043... and recommended for community studies and primary care, especially in developing countries, because they comply with the requirements proposed by the WHO¹¹11 Gonçalves DM, Stein AT, Kapczinski F. Performance of the Self-Reporting Questionnaire as a psychiatric Screening questionnaire: a comparative study with Structured Clinical Interview for DSM-IV-TR. Cad. Saúde Publica. [internet]. 2008 [acesso em 2018 jul 30]; 24(2):380-390. Disponível em: http://dx.doi.org/10.1590/S0102-311X2008000200017.
http://dx.doi.org/10.1590/S0102-311X2008... . For this purpose, the instrument evaluates the presence of 20 psychosomatic symptoms, that is, of physical symptoms (such as pain, tremors and gastrointestinal disorders), whose origin involves emotional mechanisms¹⁰10 Harding TW, de Arango MV, Baltazar J, et al. Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries. Psychol Med. [internet]. 1980 [acesso em 2018 jul 30]; 10(2):231-241. Disponível em: http://dx.doi.org/10.1017/S0033291700043993.
http://dx.doi.org/10.1017/S0033291700043... . In the general population, it is estimated that 5.8% of individuals with 18 years of age or older develop depression and that 9.3% have anxiety⁹9 World Health Organization. Depression and other common mental disorders: Global health estimates. Geneva: WHO; 2017 [acesso em 2018 set 13]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf?sequence=1.
https://apps.who.int/iris/bitstream/hand... . Among PLHIV, it is estimated that 50% have at least one episode of depression throughout their lives and that 40% are diagnosed with anxiety disorders¹²12 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Brasília, DF: MS; 2018..

Depression and anxiety represent the most important psychiatric disorders among adults living with HIV. However, such disorders are underdiagnosed because their indicators can be mimicked by physical symptoms of the infection and HAART. In this regard, the adverse effects of efavirenz, a Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI), act as confounding factors of depression symptoms¹²12 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Brasília, DF: MS; 2018..

It is also known that depressive symptoms are strongly associated with poor adherence to treatment¹³13 Aibibula W, Cox J, Hamelin AM, et al. Association between depressive symptoms, CD4 count and HIV viral suppression among HIV-HCV co-infected people. AIDS care. [internet]. 2018 [acesso em 2018 jul 28]; 30(5):643-649. Disponível em: https://doi.org/10.1080/09540121.2018.1431385.
https://doi.org/10.1080/09540121.2018.14... , and may lead to worse control of viral replication. However, there are few studies that evaluate the influence of CMD on the clinical evolution of PLHIV in relation to viral load.

In this context, the present study was carried out with the objective of investigating the association between CMD and viral load of PLHIV in clinical follow-up by the reference service of the city of Santos (SP).

Material and methods

This was a cross-sectional study, in which the population was composed of 2,000 PLHIV linked to and retained in the SCS of the city of Santos (SP), that is, those assisted and clinically monitored by the SCS in the year 2014. In this population, only adult men and women were included in the study, aged 18 years and over, in clinical follow-up by the SCS of Santos (SP) and receiving HAART. Considering a level of significance of 5%, sampling error of 0.05 and admitting variations of ±5%, a sample of 292 people was calculated. Estimating a sample loss of 10%, the final sample consisted of 322 people (G* Power). Fifteen participants who presented incomplete or inconsistent questionnaires were excluded, totaling a sample of 307 people.

Data collection was performed at the SCS itself, from February to June 2016, on alternate days and times (from Monday to Friday, from 8:00 am to 6:00 pm, according to the local assistance schedule). The instrument of data collection consisted of a questionnaire, which was applied in the form of an interview by graduate scholars. The interviews lasted for an average of 45 minutes each, and the graduates were properly trained to guide the participants, but without interfering in their responses.

Data regarding viral load were obtained through Siscel (Control System for Laboratory Tests of CD4/CD8 and Viral Load), accessed directly at the SCS of Santos. The result of the laboratory examination closest to the date of the interview of each participant was used, and this interval did not exceed six months. This interval was established based on the Clinical Protocol and Therapeutic Guidelines for Treatment of HIV Infected Adults¹²12 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Brasília, DF: MS; 2018., which recommends that the viral load test for laboratory monitoring of PLHIV in clinical follow-up should be performed every six months.

To describe the sample, socio-demographic data were obtained (birth sex, gender identity, age, marital status, education, paid activity and financial difficulties at the end of the month), lifestyle (alcoholism, smoking, use of illicit drugs and practice of physical activity) and HIV infection (time of diagnosis, time of HAART, change of scheme and use of efavirenz).

The study-dependent variable was the viral load quantification using the RT-PCR assay (Abbott Real Time HIV-1). Viral load was considered undetectable when <50 copies/ml of blood⁵5 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Relatório de Monitoramento Clínico do HIV. Brasília, DF: MS; 2018.. The independent variable comprised the CMD, evaluated by the validated version and translated into Portuguese of the SRQ2011. Of the 20 dichotomous questions (yes or no) that make up the questionnaire, those who answered affirmatively to seven or more questions were classified as positive for CMD: 1) Do you have frequent headaches? 2) Do you have lack of appetite? 3) Do you have bad sleep? 4) Do you get scared easily? 5) Do you have shaky hands? 6) Have you been feeling nervous, tense or worried? 7) Do you have poor digestion? 8) Do you have unpleasant sensations in your stomach? 9) Do you have difficulty thinking clearly? 10) Have you been feeling sad lately? 11) Have you been cried more than usual? 12) Do you have difficulty performing your daily activities with satisfaction? 13) Do you have difficulties reaching decisions? 14) Do you have difficulties at your work (is it painful, causes suffering)? 15) Do you feel unable to play an useful role in life? 16) Have you been lost interest in things? 17) Do you feel like an useless person, without purpose? 18) Have you had the idea to end life? 19) Do you feel tired all the time? 20) Do you feel tired with ease?

The data treatment included the description of the sample studied by the absolute and relative frequencies of the qualitative variables. To test the normality of the quantitative variables, the Shapiro-Wilk test was used. Parametric variables were described by mean and standard deviation (SD), while nonparametric variables were described by median and interquartile range (IQR = P25-P75).

In order to compare viral load averages according to the CMD, generalized linear models (GLM) were carried out, having as adjustment variables: birth sex, age, HIV diagnosis time, HAART time (both in years) and current use of efavirenz. In all tests, a significance level of p-value <0.05 was adopted. The analyzes were carried out in softwares Stata 12.0 and STATISTICA 7.0.

The study was authorized by the Municipal Health Department of Santos and approved by the Research Ethics Committee of the Catholic University of Santos (nº 1.237.142/2015).

Results

The study included 307 PLHIV aged 21.2-80.2 years and mean of 47.9 years (SD 12.0 years), of which 52.4% were female. Regarding gender identity, 54.9% were identified as women, 49.5% were single, 33.9% had completed secondary school, 60.3% did not exercise paid work and 39.2% mentioned always face financial difficulties at the end of the month (table 1).

With regard to lifestyle, 24.4% of the participants were smokers and reported using (10.1%) or have already made used (21.2%) of illicit drugs, with marijuana (19.5%), and cocaine (17.9%) the most cited drugs; 96.4% refused to consume alcoholic beverages and 81.1% reported not practicing physical activities (table 2).

Median time to HIV diagnosis was 12.0 years (IQR = 6.0-20.0 years); and the median time of HAART among all respondents was 8.0 years (IQR = 3.0-18.0 years). However, among the 49.7% of the participants who had already changed their therapeutic regimen at least once, the median of the current use of the current regimen was 5.0 years (IQR = 3.0-10.0 years). It was found that 44.2% used a regimen that included efavirenz.

Of the assessed PLHIV, 28.8% had detectable viral load, and 33.2% were classified as positive for CMD. There was a statistically significant association between CMD and detectable viral load, even after adjustment for birth sex, age, time of diagnosis, time of exposure to HAART, and current use of efavirenz (figure 1).

By analyzing the symptoms for CMD tracking investigated by the SRQ-20, six were associated with detectable viral load, such as: poor sleep, unpleasant sensations in the stomach, difficulty in thinking clearly, feeling sad lately, feeling an useless person and had the idea of ending life (table 3).

Discussion

A statistically significant relationship between CMD and detectable viral load is verified. A similar finding is presented by Leserman and collaborators¹⁴14 Leserman J, Jackson ED, Petitto JM, et al. Progression to AIDS: the effects of stress, depressive symptoms, and social support. Psychosom. med. [internet]. 1999 [acesso em 2018 set 9]; 61(3):397-406. Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/10367622.
https://www.ncbi.nlm.nih.gov/pubmed/1036... , who verified that depressive symptoms were associated with the rapid clinical progression of Aids in asymptomatic homosexual men who were not on HAART. Camargo and collaborators¹⁵15 Camargo LA, Capitão CG, Filipe EMV. Mental health, family support and treatment adherence: associations in the contexto of HIV/AIDS. Psico USF [internet]. 2014 [acesso em 2018 set 7]; 19(2):221-232. Disponível em: http://dx.doi.org/10.1590/1413-82712014019002013.
http://dx.doi.org/10.1590/1413-827120140... , on the other hand, identified a negative correlation between viral load and psychic stress, indicating that PLHIV with detectable viral load have fewer mental changes.

In the current situation of controlling the epidemic, which remains a challenge to public health, the evaluation of psychic disorders as potential confounding factors of the clinical evolution of PLHIV has become essential. As highlighted by the Clinical Protocol and Therapeutic Guidelines for Treatment of HIV Infected Adults¹²12 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Brasília, DF: MS; 2018., recently updated by the Ministry of Health, in addition to the changes resulting from the infection and the adverse effects of HAART mentioned previously, social limitations are among the risk factors for the development of CMD. Among them, are the difficulties related to professional activities and interpersonal relationships, to sexual and loving relationships and to the decision to have children or not¹⁶16 Arseniou S, Arvaniti A, Samakouri M. HIV infection and depression. Psychiatry clin. neurosci. [internet]. 2014 [acesso em 2019 jan 29]; 68:96-109. Disponível em: http://dx.doi.org/10.1111/pcn.12097.
http://dx.doi.org/10.1111/pcn.12097... .

It is also worth noting that, over and above the social limitations related to living with HIV and being on HAART, the clinical history in mental health prior to infection should be considered as an important factor associated with clinical evolution. This aspect, which is difficult to investigate, when added to the aforementioned ones - social issues, adverse drug effects -, can significantly affect adherence to treatment¹²12 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Brasília, DF: MS; 2018..

In addition, it is verified that the relationship between mental health and clinical evolution occurs in a bidirectional way. On the one hand, PLHIV who have psychic disorders become more vulnerable to problems related to the perception and interpretation of the health complications to which they are subject. Thus, it is possible that mental health problems negatively impact clinical evolution even when the individual adheres adequately to HAART. On the other hand, infection, the emergence of comorbidities related to HIV and a worse clinical prognosis may trigger or worsen psychic disorders previously controlled or not yet manifested¹²12 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Brasília, DF: MS; 2018..

Emotional stress can manifest itself both in the form of physical alterations, and sleep disturbances, headaches, fatigue and inappetence, as well as through depressive, anxiety and suicidal ideation¹⁷17 Chen W, Shiu CS, Yang JP, et al. Fatigue and sleep disturbance related to perceived stress in Chinese HIV-positive individuals: a mixed methods study. J AIDS Clin Res. [internet]. 2013 [acesso em 2018 jul 30]; 4:214. Disponível em: http://dx.doi.org/10.4172/2155-6113.1000214.
http://dx.doi.org/10.4172/2155-6113.1000... . In the present study, sleeping poorly and having unpleasant sensations in the stomach were the physical changes significantly associated with higher viral load among the assessed PLHIV.

During the 1990s, sleep disorders in PLHIV were primarily associated with immunosuppression. However, given its persistence even in situations of optimal control of viral replication, its occurrence has been less attributed to specific infection factors and more related to psychosocial stress¹⁸18 Allavena C, Guimard T, Billaud E, et al. Prevalence and risk factors of sleep disturbance in a large HIV-infected adult population. AIDS behav. [internet]. 2015 [acesso em 2018 jul 28]; 20(2):339-344. Disponível em: http://dx.doi.org/10.1007/s10461-015-1160-5.
http://dx.doi.org/10.1007/s10461-015-116... . Several findings regarding the relationship between immune status and sleep quality in PLHIV are found in the literature. While some studies observe an inverse correlation¹⁹19 Lee KA, Gay C, Portillo CJ, et al. Types of sleep problems in adults living with HIV/AIDS. J Clin Sleep Medicine [internet]. 2012 [acesso em 2018 jul 30]; 8(1):67-75. Disponível em: http://dx.doi.org/10.5664/jcsm.1666.
http://dx.doi.org/10.5664/jcsm.1666... ^,2020 Oshinaike O, Akinbami A, Ojelabi O, et al. Quality of sleep in an HIV population on antiretroviral therapy at an urban tertiary centre in Lagos, Nigeria. Neurol res int. [internet]. 2014 [acesso em 2018 jul 30]; 24. Disponível em: http://dx.doi.org/10.1155/2014/298703.
http://dx.doi.org/10.1155/2014/298703... , others do not find significant results²¹21 Ferreira LTK, Ceolim MF. Qualidade do sono em portadores do vírus da imunodeficiência humana. Rev. Esc. Enferm. USP. [internet]. 2012 [acesso em 2018 jul 30]; 46(4):892-899. Disponível em: http://dx.doi.org/10.1590/S0080-62342012000400016.
http://dx.doi.org/10.1590/S0080-62342012... . These differences, as the authors justify, may be due to the absence of a gold standard for the evaluation of sleep of PLHIV.

As with sleep disorders, PLHIV are more prone to the development of gastrointestinal symptoms²²22 Santo RE, Grinsztejn B, Peres WAF, et al. Bioimpedance and anthropometry in determining body composition in HIV men. Rev. bras. nutr. clín. [internet]. 2016 [acesso em 2018 jul 30]; 31(1):60-64. Disponível em: http://www.braspen.com.br/home/wp-content/uploads/2016/11/12-Bioimped%C3%A2ncia-e-antropometria.pdf.
http://www.braspen.com.br/home/wp-conten... . Although its etiology is not fully understood, there seems to be an important relationship between immune status and gastrointestinal disorders. Chronic inflammation, which is caused by HIV itself and can also be induced by prolonged exposure to HAART, promotes the continuous activation of the immune system. As a consequence, there is a homeostatic imbalance of the lymphoid tissue associated to the intestine²³23 Tasca KI. Marcadores de ativação imune, inflamação crônica e estresse oxidativo em pessoas que vivem com o HIV/Aids: a busca do melhor prognóstico [tese]. Botucatu: Faculdade de Medicina, Universidade Estadual Paulista 'Júlio de Mesquita Filho'; 2016. 135 p..

With regard to tracking symptoms for depressive and anxious disorders, scores on difficulty in thinking clearly, feeling sad lately, feeling unhelpful, and having the idea of ending life were significant. These symptoms may be associated with uncertainties in disease progression, fear of physical changes, pain, suffering, and death. When prolonged, they constitute a pathological picture that generates professional and/or social damages¹²12 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Brasília, DF: MS; 2018..

Suicidal ideation, in turn, arises in many cases of depressive symptomatology. In studies investigating suicidal ideation among PLHIV, it was found that the death wish is strongly correlated with depression scores¹⁵15 Camargo LA, Capitão CG, Filipe EMV. Mental health, family support and treatment adherence: associations in the contexto of HIV/AIDS. Psico USF [internet]. 2014 [acesso em 2018 set 7]; 19(2):221-232. Disponível em: http://dx.doi.org/10.1590/1413-82712014019002013.
http://dx.doi.org/10.1590/1413-827120140... . For this reason, it can help to distinguish the symptoms of infection and the adverse effects of HAART from a psychopathology¹²12 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Brasília, DF: MS; 2018..

Compared with WHO estimates⁹9 World Health Organization. Depression and other common mental disorders: Global health estimates. Geneva: WHO; 2017 [acesso em 2018 set 13]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf?sequence=1.
https://apps.who.int/iris/bitstream/hand... for the general population, the present study found a high prevalence of CMD among participants. Reis and collabortors²⁴24 Reis RK, Melo ES, Castrighini CC, et al. Prevalence and factors associated with depressive symptoms in individuals living with HIV/AIDS. Salud ment. [internet]. 2017 [acesso em 2018 set 7]; 40(2):57-62. Disponível em: https://doi.org/10.17711/SM.0185-3325.2017.008.
https://doi.org/10.17711/SM.0185-3325.20... , when assessing PLHIV in São Paulo (SP), found a prevalence of 42.3% of depressive and anxious symptoms. The authors also found an association between symptoms and CD4 T lymphocytes <200 cells/mm³, but did not assess the viral load of the participants.

About 30% of participants had detectable viral load, a percentage similar to that reported in the HIV5 Clinical Monitoring Report for PLHIV aged 18 years or older on HAART for at least six months. However, data referring to the year 2015, reported by the SCS of Santos, indicate that 55% of PLHIV using HAART were virally suppressed³3 Etzel A, Silva NG, Lacerda R, et al. Cascata do cuidado contínuo em HIV/Aids em Santos-SP 2015. In: Anais do 31º Congresso de Secretários Municipais de Saúde do Estado de São Paulo; 2017 Mar; Santos. Santos: Secretaria Municipal de Saúde; 2017.. Based on these results, it is possible to observe that the percentage of PLHIV in viral suppression in the municipality was well below the state of São Paulo and the Country in the year 2016, when the data were collected, 85% and 84% respectively. However, the observed reduction in the percentage of detectable viral load in the municipality, from 55.0% in 2015 to 28.8% in 2016, can be attributed to the frequent campaigns of prevention and testing for diagnosis and early treatment of HIV promoted by the National Coordination Centre for Communicable Disease Control.

The occurrence of psychiatric disorders and worst indicators of the clinical evolution of PLHIV also seems to be associated with the use of psychoactive substances, smoking, sedentary lifestyle and unbalanced eating¹²12 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Brasília, DF: MS; 2018.. In this aspect, the high prevalence of sedentarism, smoking and drug use verified by the present study also deserve attention.

The prevalence of sedentary PLHIV in this study far exceeds that observed in the general population. According to the National Health Survey - PNS 2013²⁵25 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas - Brasil e Grandes Regiões. Rio de Janeiro: IBGE; 2014., 46.0% of adults are considered insufficiently active. In a systematic review of the effects of different types of exercises on PLHIV, Gomes-Neto and collaborators²⁶26 Gomes Neto M, Conceição CS, Carvalho VO, et al. A systematic review of the effects of different types of therapeutic exercise on physiologic and functional measurements in patients with HIV/AIDS. Clinics. [internet]. 2013 [acesso em 2018 jul 30]; 68(8):1157-1167. Disponível em: http://dx.doi.org/10.6061/clinics/2013(08)16.
http://dx.doi.org/10.6061/clinics/2013(0... found that regular practice contributes positively to physical, personal and social aspects, minimizing stress, improving the perception of one’s own abilities and satisfaction with life. Ferreira and Ceolim²¹21 Ferreira LTK, Ceolim MF. Qualidade do sono em portadores do vírus da imunodeficiência humana. Rev. Esc. Enferm. USP. [internet]. 2012 [acesso em 2018 jul 30]; 46(4):892-899. Disponível em: http://dx.doi.org/10.1590/S0080-62342012000400016.
http://dx.doi.org/10.1590/S0080-62342012... also highlight sleep regulation, preservation of immune function and reduction of the adverse effects of HAART.

Regarding smoking, according to data from PNS 2013²⁵25 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: Percepção do estado de saúde, estilos de vida e doenças crônicas - Brasil e Grandes Regiões. Rio de Janeiro: IBGE; 2014., 15.0% of Brazilian adults use products derived from tobacco daily or occasionally. Thus, like the present study, many authors report prevalence up to two times bigger among PLHIV compared to the general population²²22 Santo RE, Grinsztejn B, Peres WAF, et al. Bioimpedance and anthropometry in determining body composition in HIV men. Rev. bras. nutr. clín. [internet]. 2016 [acesso em 2018 jul 30]; 31(1):60-64. Disponível em: http://www.braspen.com.br/home/wp-content/uploads/2016/11/12-Bioimped%C3%A2ncia-e-antropometria.pdf.
http://www.braspen.com.br/home/wp-conten... ^,2727 Kroll AF, Sprinz E, Leal SC, et al. Prevalence of obesity and cardiovascular risk in patients with HIV/AIDS in Porto Alegre, Brazil. Arq. bras. endocrinol. metab. [internet]. 2012 [acesso em 2018 jul 30]; 56(2):137-141. Disponível em: http://dx.doi.org/10.1590/S0004-27302012000200007.
http://dx.doi.org/10.1590/S0004-27302012... ^,2828 Schouten J, Wit FW, Stolte IG, et al. Cross-sectional comparison of the prevalence of age-associated comorbidities and their risk factors between HIV-infected and uninfected individuals: the AGEhIV Cohort Study. Clin. infect. dis. [internet]. 2014 [acesso em 2018 jul 30]; 59(12):1787-1797. Disponível em: https://doi.org/10.1093/cid/ciu701.
https://doi.org/10.1093/cid/ciu701... .

Finally, in relation to illicit drugs, the prevalence of PLHIV that they used or have already used was about four times superior than that observed in the general population. According to the World Drug Report 2017²⁹29 United Nations Office on Drugs and Crime. World Drug Report 2017. United Nations Publication [acesso em 2018 set 13]. Disponível em: https://doi.org/10.18356/c595e10f-en.
https://doi.org/10.18356/c595e10f-en... , 5.0% of the adult population have already used drugs at least once in their lifetime. Data from the II National Survey on Alcohol and Drugs (Lenad)³⁰30 Instituto Nacional de Ciência e Tecnologia para Políticas Públicas do Álcool e Outras Drogas. Unidade de pesquisas em álcool e drogas. II Levantamento Nacional de Álcool e Drogas (LENAD) 2012. Laranjeira R., organizador. São Paulo: UNIFESP, 2014 [acesso em 2018 set 13]. Disponível em: https://inpad.org.br/wp-content/uploads/2014/03/Lenad-II-Relat%C3%B3rio.pdf.
https://inpad.org.br/wp-content/uploads/... indicate that 5.8% of Brazilians have ever used drugs and that 2.5% used them in the last 12 months that preceded the study. As in the above surveys, marijuana represented the main substance used.

The results presented reinforce the importance of mental health care for PLHIV as part of a set of non-pharmacological interventions aimed at optimizing the response to HAART and stimulating the active search for a healthier lifestyle.

Although the present study is of extreme relevance to public health, it presents some limitations that need to be punctuated. The instrument used to track CMD evaluates the current presence of psychosomatic symptoms, while the viral load quantification test used in the present study may have been performed within an interval of up to six months. Although this is the range recommended by the current guidelines for clinical HIV monitoring, this difference between the time of the test and the implementation of the questionnaire may represent a possible confounding factor for the reported association. Another limitation is the impossibility of establishing a temporal relation of cause and effect between the evaluated variables. On the other hand, the results found are supported by previous studies⁸8 Tunala LG. Daily sources of stress among HIV-positive women. Rev. saúde pública [internet]. 2002 [acesso em 2018 jul 30]; 36(4):24-31. Disponível em: http://dx.doi.org/10.1590/S0034-89102002000500005.
http://dx.doi.org/10.1590/S0034-89102002... ^,1212 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde, Departamento de Vigilância, Prevenção e Controle das IST, do HIV/Aids e das Hepatites Virais. Protocolo clínico e diretrizes terapêuticas para manejo da infecção pelo HIV em adultos. Brasília, DF: MS; 2018.

13 Aibibula W, Cox J, Hamelin AM, et al. Association between depressive symptoms, CD4 count and HIV viral suppression among HIV-HCV co-infected people. AIDS care. [internet]. 2018 [acesso em 2018 jul 28]; 30(5):643-649. Disponível em: https://doi.org/10.1080/09540121.2018.1431385.
https://doi.org/10.1080/09540121.2018.14... ^-1414 Leserman J, Jackson ED, Petitto JM, et al. Progression to AIDS: the effects of stress, depressive symptoms, and social support. Psychosom. med. [internet]. 1999 [acesso em 2018 set 9]; 61(3):397-406. Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/10367622.
https://www.ncbi.nlm.nih.gov/pubmed/1036... ^,1616 Arseniou S, Arvaniti A, Samakouri M. HIV infection and depression. Psychiatry clin. neurosci. [internet]. 2014 [acesso em 2019 jan 29]; 68:96-109. Disponível em: http://dx.doi.org/10.1111/pcn.12097.
http://dx.doi.org/10.1111/pcn.12097... ^,1717 Chen W, Shiu CS, Yang JP, et al. Fatigue and sleep disturbance related to perceived stress in Chinese HIV-positive individuals: a mixed methods study. J AIDS Clin Res. [internet]. 2013 [acesso em 2018 jul 30]; 4:214. Disponível em: http://dx.doi.org/10.4172/2155-6113.1000214.
http://dx.doi.org/10.4172/2155-6113.1000... , strengthening this way the associations found. Furthermore, due to the scarcity of data on the topic addressed here and the current situation of the HIV epidemic, studies of this nature are fundamental to raise hypotheses and provide subsidies for other types of study³¹31 Bonita R, Beaglehole R, Kjellström T. Epidemiologia básica. 2. ed. São Paulo: Livraria Santos Editora Comp. Imp. Ltda.; 2010.. In this aspect, a strong point of this study is the description of a significant sample of PLHIV using HAART in relation to the CMD tracking and clinical evolution, as well as in the identification of a significant association between these stated variables. From the results presented, it will certainly be possible to contribute to the discussions of public policies to promote the mental health of this population.

Conclusions

CMD are associated with a higher viral load among PLHIV in clinical follow-up. Given the above, the need for investigation protocols and management of mental disorders to better understand their effects on the clinical evolution of PLHIV is emphasized. Early diagnosis and appropriate treatment may significantly contribute to a better outcome of co-morbidities associated or not with HIV.

Acknowledgements

We thank the volunteers who participated in the study, for their valuable contribution; the Coordination Centre for Communicable Diseases Control of the Surveillance Department of the Municipal Secretariat of Santos, for all the support; the National Council for Scientific and Technological Development (CNPq), for the grant to carry out the research (universal edict nº 455046/2014-0); the Coordination for the Improvement of Higher Education Personnel for the masters and doctorate scholarships (Capes nº 88887.15021/2017-00 and 88887.150178/2017-00, respectively); the CNPq for the Scientific Initiation scholarship (CNPq nº 150781/2017-2).

References

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