Monitoramento da adesão ao tratamento antirretroviral no Brasil: um urgente desafio

• Ano de defesa: 2010
• Autor(a) principal: Gustavo Machado Rocha
• Tipo de documento: Dissertação
• Tipo de acesso: Acesso aberto
• Idioma: por
• Instituição de defesa: Universidade Federal de Minas Gerais; UFMG
• Palavras-chave em Português: Saúde pública; Terapia anti-retroviral de alta atividade; Carga viral; Síndrome de imunodeficiência adquirida/quimioterapia; Linfócitos T CD4-positivos; Resultado de tratamento; Contagem de linfócitos; Adesão à medicação; Infecções por HIV/quimioterapia; Recusa do paciente ao tratamento
• Link de acesso: http://hdl.handle.net/1843/ECJS-84ZGLH

After introduction of combined antiretroviral therapy, AIDS stopped to be a high fatal and became a chronic and potentially controllable disease. However therapeutic success remains a great challenge because, among other factors, sustained high rates of drug adherence are necessary. The aim of this study was to describe the effect of nonadherence on the main laboratory outcomes, TCD4+ lymphocyte count and HIV viral load, routinely used to monitor patients initiating treatment according to three different approaches to measure adherence to antiretroviral therapy. Additionally, a systematic review was performed, with emphasis on Brazilian studies, to produce an average nonadherence rate estimative. This study is part of ATAR project, a prospective study among patients beginning antiretroviral therapy in two public referral health services in Belo Horizonte, Brazil. Recruitment and baseline assessment occurred at the moment of first prescription and follow-up during the first year of treatment. Gain in TCD4+ lymphocytes and loss in HIV viral load were compared between adherent and nonadherent patients by independent sample t-tests and analysis of variance after at least four months and up to twelve months of treatment. Among 176 studies included on systematic review, 42.6% were done in United States and 6.8% in Brazil. Self-report was the major adherence measure used (71.0%), followed by pharmacy refill records (17.1%). Meta-analyses among Brazilian studies (N=13) produced an average nonadherence rate of 34.4% (95% CI 27.5%-42.1%). Among 288 participants of ATARproject that filled criterion for this analysis, 22.9%, 31.9% and 74.3% were considered non-adherent, according to medical charts, self-report and pharmacy records,respectively. Using self-report measure, the average gain in TCD4+ lymphocytes was144.6 cells/mm3 and the average loss in viral load was 4.52 log for adherent patients,comparing with an average gain of 86.3 TCD4+ lymphocytes/mm3 (p=0.023) and an average loss of 2.73 log in viral load (p<0.001) for those non-adherent. According to pharmacy records, patients with regular prescription pickups achieved average gain of 195.4 TCD4+ lymphocytes/ mm3 and average loss of 4.62 log of viral load. On theother hand, among those with irregular pickups and permanent drop-out, the averagegain was 99.8 and 90.3 TCD4+ lymphocytes/ mm3 (p<0.001), with mean reduction of 4.07 and 2.41 in viral load (p<0.001), respectively. Analyzing medical records, there was a mean increase of 142.4 for adherent patients and 58.5 TCD4+ lymphocytes/ mm3 for those non-adherent (p<0.001), with a mean viral load reduction of 4.25 for adherentand 1.99 for non-adherent patients (p<0.001). Adherent patients clearly achieved greater average gain in lymphocytes TCD4+ and loss in viral load than those non-adherents. Besides this difference varied according to the type of drug adherence measure used, the potential impact of antiretroviral non-adherence is evident on those referral health services, as much in immunologic recuperation as in virologic response. Continuously and effectively monitoring of antiretroviral adherence should be considered a priority in these public AIDS referral centers in order to identify patients at high risk of developing virologic failure. Early interventions are necessary in order to maintain the initial therapeutic regimens for longer periods.