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      Self-perception of knowledge and adherence reflecting the effectiveness of antiretroviral therapy

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          To evaluate which indirect method for assessing adherence best reflects highly active antiretroviral therapy (HAART) effectiveness and the factors related to adherence.


          This descriptive, cross-sectional study was performed in 2012 at a reference center of the state of São Paulo. Self-report (simplified medication adherence questionnaire [SMAQ]) and drug refill parameters were compared to the viral load (clinical parameter of the effectiveness of pharmacotherapy [EP]) to evaluate the EP. The “Cuestionario para la Evaluación de la Adhesión al Tratamiento Antiretroviral” (CEAT-VIH) was used to evaluate factors related to adherence and the EP and, complementarily, patient self-perception of adherence was compared to the clinical parameter of the EP.


          Seventy-five patients were interviewed, 60 of whom were considered as adherent from the clinical parameter of the EP and ten were considered as adherent from all parameters. Patient self-perception about adherence was the instrument that best reflected the EP when compared to the standardized self-report questionnaire (SMAQ) and drug refill parameter. The level of education and the level of knowledge on HAART were positively correlated to the EP. Forgetfulness, alcohol use, and lack of knowledge about the medications were the factors most frequently reported as a cause of nonadherence.


          A new parameter of patient self-perception of adherence, which is a noninvasive, inexpensive instrument, could be applied and assessed as easily as self-report (SMAQ) during monthly drug refill, since it allows monitoring adherence through pharmaceutical assistance. Therefore, patient adherence to HAART could be evaluated using self-perception (CEAT-VIH) and the viral load test.

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          Most cited references 29

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          Less than 95% adherence to nonnucleoside reverse-transcriptase inhibitor therapy can lead to viral suppression.

          For antiretroviral therapy, the 95% adherence "threshold" is based on nucloside-exposed patients who are receiving partially suppressive, unboosted protease inhibitor regimens. Using unannounced pill counts and electronic medication monitoring, viral suppression is common with a 54%-100% mean adherence level to nonnucleoside reverse-transcriptase-inhibitor regimens. Although perfect adherence is an important goal, viral suppression is possible with moderate adherence to potent regimens.
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            Validation of a simplified medication adherence questionnaire in a large cohort of HIV-infected patients: the GEEMA Study.

            To assess the effectiveness of the simplified medication adherence questionnaire (SMAQ) in identifying non-adherent patients. Prospective observational study of adherence. The six-item SMAQ was developed. The following aspects were evaluated: (i) criterion validity, comparison with electronic adherence monitoring; (ii) construct validity, association between adherence, as defined by the SMAQ, and virological outcomes; and (iii) reliability, internal consistency and reproducibility. A group of 3004 unselected HIV patients who had initiated nelfinavir therapy combined with other antiretroviral drugs [21% naive, 15% protease inhibitor (PI)-naive, 64% PI-experienced] between January 1998 and December 1999 were enrolled in 69 hospitals in Spain. The SMAQ was administered at months 3, 6 and 12. The SMAQ showed 72% sensitivity, 91% specificity and a likelihood ratio of 7.94 to identified non-adherent patients, compared with the medication-event monitoring system (40 patients evaluated). At month 12, 1797 patients were evaluated, of whom 32.3% were defined as non-adherent; viral load 5 log10/ml, CD4 cell count < 200 x 10(6)/l, and non-adherence as independent variables. Non-adherence was the only significant risk factor in failing to achieve virological suppression. Cronbach's alpha internal consistency coefficient was 0.75, and overall inter-observer agreement was 88.2%. The SMAQ appears to be an adequate instrument with which to assess adherence in HIV-infected patients, and may be applied in most clinical settings.
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              Addressing the challenges of adherence.

              Adherence to antiretroviral therapy is a crucial determinant of treatment success. Studies have unequivocally demonstrated the close association between adherence and plasma HIV RNA levels, CD4 cell counts, and mortality in patients with HIV infection and disease. Adherence levels of > or =95% are required to maintain virologic suppression. However, actual adherence rates are often far lower; most studies show that 40% to 60% of patients are <90% adherent. Adherence also tends to decrease over time. Patients offer a range of reasons for nonadherence, but the most frequently cited one is simply that they forget; other reasons include being away from home, being busy, or experiencing a change in daily routine. Additional barriers to adherence include psychiatric disorders, such as depression or substance use, uncertainty about the effectiveness of treatment and the consequences of poor adherence, regimen complexity, and treatment side effects. Several strategies can be employed in the effort to support patients' adherence, and all members of the multidisciplinary team should ideally employ these strategies in combination. Efforts should be made to educate and motivate patients, simplify treatment regimens and tailor them to individual lifestyles, prepare for and manage side effects, and address the concrete issues that may be a barrier to adherence. Recruiting an adherence monitor, providing memory aids to medication taking, and anticipating course corrections can also help patients achieve the adherence rates needed for successful treatment of HIV infection and disease.

                Author and article information

                Patient Prefer Adherence
                Patient Prefer Adherence
                Patient Preference and Adherence
                Patient preference and adherence
                Dove Medical Press
                13 September 2016
                : 10
                : 1787-1793
                [1 ]Department of Drugs and Medications, School of Pharmaceutical Sciences of the UNESP – Univ Estadual Paulista, Araraquara
                [2 ]Department of Surgery and Anatomy, Americo Brasiliense State Hospital
                [3 ]Department of Psychobiology, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
                Author notes
                Correspondence: Patricia de Carvalho Mastroianni, Department of Drugs and Medications, School of Pharmaceutical Sciences of the UNESP – Univ Estadual Paulista, Rodovia Araraquara – Jaú, km 1, Araraquara, São Paulo, CEP 14801-902, Brazil, Tel +55 16 3301 6977, Fax +55 16 3322 0073, Email patriciamastroianni@
                Tales Rubens de Nadai, Department of Surgery and Anatomy, Americo Brasiliense State Hospital, Alameda Aldo Lupo 1260, Américo Brasiliense, São Paulo 14820-000, Brazil, Email talesusp@
                © 2016 Dagli-Hernandez et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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