Antiretroviral Therapy Adherence, Gender, and Drug ...

Antiretroviral Therapy Adherence, Gender, and Drug Use:

Factors Associated with Physical and Psychological Symptoms in People Living with HIV from Northern Viet Nam K. Green , T. Tran , H. Tran Vu , H. Nguyen Duc , G. Arnolda , P. Vu Ngoc , T.H. Nguyen Thi 1

2

BACKGROUND

ʳ Studies have reported associations between symptoms, poor adherence to antiretroviral therapy (ART), and disease progression.(1-3) ʳ Poor provider detection and management of symptoms has been identified in routine HIV care. (4,5) ʳ Limited data exists on the prevalence of symptoms among PLHIV in Asia, especially those on ART.

FIGURE 1. Northern Viet Nam

3

ʳ A mixed-method longitudinal controlled trial was conducted to test strategies to improve symptom management, mental health, and social support in PLHIV in two HIV outpatient clinics: Cam Pha District (control) and Van Don District (intervention) in Quang Ninh, Viet Nam.

ʳ Primary study outcomes were the prevalence and severity of symptoms including pain, the prevalence of depression and anxiety, and degrees of social support. The Memorial Symptom Assessment Scale (MSAS) was used to measure symptom prevalence, burden (average number of symptoms reported), and three sub-scales: physical symptom distress, psychological symptom distress, and global symptom distress. Results from the MSAS at baseline are reported in this poster.

ʳ The intervention included techniques to aid the screening and treatment of symptoms (introduction of a short screening tool and mentoring of clinicians in symptom management), management of depression and anxiety, and provision of social support (use of screening tools and provision of mental health care and social support services).

ʳ Baseline data were analyzed to quantify demographic and clinical variables, quantify factors associated with symptoms, and test for differences in symptom outcomes by ART status (on or not on ART).

CHINA

Binh Lieu District

Tien Yan District

Bac Giang Province

Hai Ha District

Mong Cai Town

Hoanh Bo District

All

Co To District

Ha Lonh City Van Don District

Hai Phong Province EAST SEA

On ART?

N

%

Yes %

Difficulty concentrating

425

51.7

50.6

55.2

0.29

Pain

300

36.5

34.2

43.8

0.02

Lack of energy

443

53.9

52.1

59.8

0.07

Cough

357

43.4

41.9

48.5

0.12

Nervousness

269

32.7

32.2

34.5

0.54

MSAS symptoms Cam Pha Town

A total of 822 PLHIV (32% female) from the two HIV outpatient clinics were interviewed at baseline.

TABLE 1. Symptom prevalence

Dam Ha District

Ba Che District

Yen Hung District

3

RESULTS

Lang Son Province

Hai Duong Province

5

ʳ The study involved a double baseline, two rounds of post-intervention interviews, and an embedded qualitative study.

STUDY LOCATION

Uong Bi Town

4

METHODS

ʳ Physical and psychological symptoms are common in people living with HIV (PLHIV), particularly those presenting into care with CD4 counts < 200 cells/µl.

Dong Trieu District

3

No

%

pvalue*

Dry mouth

418

50.9

49.5

55.2

0.19

Nausea

204

24.8

24.5

25.8

0.78

Vomiting

100

12.2

12.1

12.4

0.90

(1) Ammassari A, Murri A, Pezzotti P, Trotta MP, Ravasio L, DeLongis P, et al. Self-reported symptoms and medication side effects influence adherence to highly active retroviral therapy in persons with HIV infection. J Acquir Immune Defic Syndr. 2001;28(5):445-9.

Drowsiness

165

20.1

18.8

24.2

0.10

Numbness/shooting pain/ tingling in hands/feet

313

38.1

36.9

41.8

0.24

(2) Heath KV, Singer J, O’Shaughnessy MV, Montaner JS, Hogg RS. Intentional nonadherence due to adverse symptoms associated with antiretroviral therapy. J Acquir Immune Defic Syndr. 2002;31(2):211-27.

Difficulty sleeping

389

47.3

47.3

47.4

1.0

Problems urinating

83

10.1

8.6

14.9

0.01

(3) Sherr L, Lampe F, Norwood S, Leake Date H, Harding R, Johnson M, et al. Adherence to antiretroviral treatment in patients with HIV in the UK: a study of complexity. AIDS Care. 2008;20(4):442-8.

Shortness of breath

169

20.6

19.7

23.2

0.31

Diarrhea

120

14.6

12.4

21.6

0.002

(4) Breitbart W, Rosenfeld BD, McDonald MV, Thaler H, Portenoy RK. The undertreatment of pain in ambulatory AIDS patients. Pain. 1996;65(23): 243-9.

Sadness

422

51.3

50.5

54.1

0.41

Sweating

220

26.8

26.3

28.4

0.58

Worrying

406

49.4

47.9

54.1

0.14

Problems with sexual interest or activity

162

19.7

19.6

20.1

0.92

Itching

191

23.2

23.6

22.2

0.77

REFERENCES

(5) Justice AC, Chang CH, Rabeneck L, Zackin R. Clinical importance of provider-reported HIV symptoms compared with patient-report. Med Care. 2001;39:397-408.

ACKNOWLEDGEMENTS

Difficulty swallowing, painful swallowing

92

11.2

10.7

12.9

0.43

Irritability

423

51.5

51.1

52.6

0.74

ʳ Clinic clients and families

Problems with vision

169

20.6

21.8

16.5

0.13

ʳ U.S. Agency for International Development (USAID) Viet Nam (Nguyen Thi Minh Ngoc, Xerxes Sidhwa)

Painful skin rash

65

7.9

7.8

8.2

0.88

Mouth sores

75

9.1

7.5

14.4

0.006

ʳ Van Don and Cam Pha District Hospitals

ʳ U.S. Centers for Disease Control and Prevention (CDC) Viet Nam (Ho Van Anh, Jodi Charles, Nick Medland) ʳ FHI 360 (Steve Mills, Nguyen Cuong Quoc, Vu Ngoc Phinh, Nguyen Thi Thanh Ha, Rachel Burdon)

AUTHOR AFFILIATIONS 1

FHI 360, Accra, Ghana

2

Research and Training Centre for Community Development, Hanoi, Viet Nam

3

FHI 360, Hanoi, Viet Nam

4

Van Don District Hospital, Van Don, Viet Nam

5

Consultant

Change in the way food tastes

119

14.5

14.5

14.4

1.0

Hair loss

253

30.8

31.5

28.4

0.42

Constipation

213

25.9

25.8

26.3

0.93

Swelling or arms of legs

36

4.4

4.5

4.1

1.0

Changes in shape of body

49

6.0

6.7

3.6

0.12

Changes in skin

218

26.5

26.4

26.8

0.93

Results showed that 73% of the study participants were on ART. The median time since initiation was 1.5 years (IQR, 95% CI=1-2). Also, 59.1% of the cohort reported a history of injecting drug use. Almost all (98.4%) of the participants reported experiencing physical and psychological symptoms in the past month. No statistical difference was found in the prevalence of symptoms between those on ART and those not on ART (p=0.38). Among participants who reported symptoms, the median number of symptoms experienced in the past month was 10 (IQR, 95% CI=6-16). Physicians at the clinics detected only 1.75% of the symptoms reported by patients during the same month. In a comparison between PLHIV on ART and those who were pre-ART, only four symptoms were found to be statistically more prevalent in the pre-ART population: pain, diarrhea, problems urinating, and mouth sores (Table 1). Poor ART adherence (p=0.001), female sex (p< 0.001), and recent injecting drug use (p=0.002) were significantly associated with a higher symptom burden. Being on ART, CD4 counts, or other clinical markers were not associated with symptom burden.

CONCLUSIONS PLHIV in this cohort experienced a high symptom burden regardless of their ART status or CD4 count. Despite this finding, physical and psychological symptoms were profoundly under-detected by HIV clinicians. Symptom burden was associated with sub-optimal ART adherence, with being female, and with a recent history of injecting drug use. Better symptom screening and management is paramount for improved well-being and better treatment outcomes in PLHIV who are pre-ART or on ART. Services also need to take into account the specific physical and psychological symptom needs of women and drug users living with HIV.

*Italicized p-value indicates overall statistically significant difference. Abbreviations: ART = antiretroviral therapy; MSAS = Memorial Symptom Assessment Scale.

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