Adesão ao tratamento antirretroviral e fatores individuais associados com não-adesão na província da Zambézia, Moçambique
Arquivos
Data
2017-11-06
Autores
Filimão, Dércio Belo Cesar 
Orientadores
Castelo Filho, Adauto
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: Esquemas de tratamento antirretroviral (TARV) de primeira linha em Moçambique são baseados em inibidores não-nucleosídoes da transcriptase reversa (INNTR) de primeira geração, que têm baixa barreira genética. Objetivos: determinar 1) o nível de adesão dos pacientes que iniciaram TARV, durante período mínimo de dois anos, na província da Zambézia, Moçambique, entre janeiro de 2013 e 30 de junho de 2014; 2) o percentual de abandono do tratamento; e 3) fatores associados com não-adesão. Métodos: Estudo de coorte retrospectivo. Em três centros foram incluídos pacientes que iniciaram TARV no período de estudo. Com base na retirada de ARVs da farmácia, não-adesão foi definida como atraso na retirada de ARVs por mais de 14 dias e abandono por atraso superior a 60 dias. Resultados: Um total de 1413 foram incluídos: 76,7% eram mulheres, 65,5% moravam em zona rural e 14,4% pertenciam a um grupo de apoio à adesão comunitária (GAAC). A média de idade foi de 32 anos (15 a 75) e o número médio de células CD4 no início de TARV foi de 398,19/mm3. Durante todo o período do estudo, somente 19% (268) dos pacientes permaneceram aderentes e 66,5% (939) abandonaram o tratamento. Ter 35 anos ou mais (OR: 0,843; p=0,012), ser atendido em zona urbana (OR: 0,754, p<0,001), receber esquema contendo Efavirenz (OR: 0,932; p=0,026) se associaram, de forma independente, com menor chance de não-adesão. Ser viúvo se associou com adesão significantemente maior que aqueles casados/união estável e solteiros, na análise univariada (p=0,01); Não pertencer a um GAAC se associou de forma independente a maior chance de não-adesão (OR: 1,431; p<0,001). Discussão e conclusões: Maior percentual de perda de adesão (44%) ocorreu já nos primeiros três meses de tratamento. Taxa de 19% adesão encontrada constitui o cenário mais otimista, uma vez que a retirada de ARVs não assegura a ingestão dos mesmos. Baixas taxas de adesão sugerem maior risco de desenvolvimento de mutações de resistência aos INNTRs e a mera adoção de esquemas significantemente mais potentes não se traduzirá em maiores taxas de supressão viral. Intervenções de melhoria devem focar o período pré-tratamento e os primeiros três meses de TARV. Ações em nível nacional e comunitário para redução do estigma, aceitação comunitária da infecção pelo HIV, descentralização do atendimento e dispensação de ARVs para melhorar o acesso dos pacientes à medicação.
Introduction: First-line antiretroviral therapy (ART) regimens in Mozambique are based on first-generation non-nucleoside reverse transcriptase inhibitors (NNRTIs), which have a low genetic barrier. Objectives: To determine 1) the two years level of adherence, for adult patients who started ART in Zambézia Province, Mozambique, between January 2013 and June 30, 2014; 2) the percentage of treatment abandonment; and 3) factors associated with non-adherence. Methods: Retrospective cohort study. Patients who initiated ART during the study period were included in the study from three health facilities. Using pick-up of ARVs from the pharmacy as our primary endpoint, “non-adherence” was defined as a delay in ARV pick-up of more than 14 days and “abandoned treatment” was defined as a delay in ARV pick-up of more than 60 days. Results: A total of 1413 participants were included: 76.7% were women, 65.5% lived in rural areas and 14.4% belonged to a Community Adherence and Support Group (GAAC). The mean age was 32 years (range: 15 to 75) and the mean number of CD4 cells at the start of ART was 398.19/mm3. Throughout the study period, only 19% (268) of patients remained adherent, with 66.5% (939) having discontinued treatment. Being 35 years old or older (OR: 0.843; p=0.012); receiving treatment in an urban area (OR: 0.754, p <0.001); and receiving an ARV regimen containing Efavirenz (OR: 0.932; p = 0.026) were associated with less chance of non-adherence. In univariate analysis, being a widow was associated with a significantly higher adherence than those reporting being married/stable union or unmarried (p=0.01). Not belonging to a GAAC was independently associated with a greater chance of non-adherence (OR: 1.431; p <0.001). Discussion and Conclusions: The largest percentage of patients lost to follow-up (44%) occurred in the first three months following treatment initiation. Our rate of 19% estimated adherence found, is the most optimistic scenario, since the pick-up of ARVs does not ensure their ingestion. Low adherence rates suggest a higher risk of developing resistance mutations to NNRTIs and the mere adoption of regimens significantly more potent will not translate into higher rates of viral suppression. Quality improvement interventions should focus on the pre-treatment period and the first three months of ART. National and community-based actions should focus on the reduction of stigma, improving community acceptance of HIV infection, and decentralization of care and ARV dispensing to improve patient access to medication.
Introduction: First-line antiretroviral therapy (ART) regimens in Mozambique are based on first-generation non-nucleoside reverse transcriptase inhibitors (NNRTIs), which have a low genetic barrier. Objectives: To determine 1) the two years level of adherence, for adult patients who started ART in Zambézia Province, Mozambique, between January 2013 and June 30, 2014; 2) the percentage of treatment abandonment; and 3) factors associated with non-adherence. Methods: Retrospective cohort study. Patients who initiated ART during the study period were included in the study from three health facilities. Using pick-up of ARVs from the pharmacy as our primary endpoint, “non-adherence” was defined as a delay in ARV pick-up of more than 14 days and “abandoned treatment” was defined as a delay in ARV pick-up of more than 60 days. Results: A total of 1413 participants were included: 76.7% were women, 65.5% lived in rural areas and 14.4% belonged to a Community Adherence and Support Group (GAAC). The mean age was 32 years (range: 15 to 75) and the mean number of CD4 cells at the start of ART was 398.19/mm3. Throughout the study period, only 19% (268) of patients remained adherent, with 66.5% (939) having discontinued treatment. Being 35 years old or older (OR: 0.843; p=0.012); receiving treatment in an urban area (OR: 0.754, p <0.001); and receiving an ARV regimen containing Efavirenz (OR: 0.932; p = 0.026) were associated with less chance of non-adherence. In univariate analysis, being a widow was associated with a significantly higher adherence than those reporting being married/stable union or unmarried (p=0.01). Not belonging to a GAAC was independently associated with a greater chance of non-adherence (OR: 1.431; p <0.001). Discussion and Conclusions: The largest percentage of patients lost to follow-up (44%) occurred in the first three months following treatment initiation. Our rate of 19% estimated adherence found, is the most optimistic scenario, since the pick-up of ARVs does not ensure their ingestion. Low adherence rates suggest a higher risk of developing resistance mutations to NNRTIs and the mere adoption of regimens significantly more potent will not translate into higher rates of viral suppression. Quality improvement interventions should focus on the pre-treatment period and the first three months of ART. National and community-based actions should focus on the reduction of stigma, improving community acceptance of HIV infection, and decentralization of care and ARV dispensing to improve patient access to medication.