This study is, to our knowledge, the first study among HIV patients in an Arctic population of living conditions and quality of life and their association with adherence and treatment outcome. The HIV population in Greenland differs from most other HIV populations throughout the world, as most patients are relatively old at the time of diagnosis, reflecting late infection rather than late diagnosis (5
), and as most are infected heterosexually. Most HIV patients in Greenland are uneducated and live alone. As the main part are unemployed they are relatively poor with 76% in our study reporting an income less than 20,000 USD per year compared with 64% of the Greenland population as a whole (1
There are no universally accepted criteria of adherence in HIV patients, and different criteria have been used (13
). We used a combination of adherence to appointments and to medication, as both are crucial for optimal infection control. According to these criteria 33% of the patients were non-adherent. Although the results are not directly comparable with other studies (10
), the fraction of non-adherent HIV patients in Greenland seemed relatively high especially when considering that 8% of the registered HIV population had refused to participate in the HIV treatment program and had skipped appointments for years.
One patient who asserted to be adherent had a viral load of more than 80,000 copies per ml despite full viral sensitivity to his treatment, which questions the validity of his statement. Even so there was such a strong association between adherence and disease control with adherent persons having substantially lower viral loads and higher CD4 counts than non-adherent patients that it, like elsewhere in the world, underlines the importance of adherence.
We found that only 2 factors were independently associated with adherence, old age and living in the capital Nuuk. Studies from other parts of the world have indicated that the health care provider's level of knowledge, experience and skills are of great importance for patient adherence, as is the level of support and encouragement (14
). In agreement with those results we found that living in a district outside of Nuuk was associated with poor adherence. While the staff situation may differ between the district hospitals, in general patients from the districts have no direct contact with HIV-committed personnel. This emphasizes the importance of having dedicated and skilled health staff members to take care of this patient group.
The finding that adherence was highest among elderly people on age pension is supported by results from other studies showing that adherence improves with age of the patient (19
). Related to the relatively high age, a large fraction of the patients were sexually inactive and many of them had no sexual needs, but sexual activity was relatively high among the young patients with poor adherence. Fifteen percent of the patients reported having had unsafe sex within the last year. The fraction might be higher since many patients refused to answer this question. It warrants attention that unsafe sex was significantly associated with non-adherence.
Although not significant, we found a trend towards higher adherence with higher income. In accordance with this it has been shown that low educational levels are associated with poorer HIV outcome (20
). Many HIV patients in Greenland are uneducated and relatively poor. Although treatment is free of charge the finding may indicate that financial situation influences compliance.
In contrast to others we found no association with HIV history such as duration of HIV or of HAART treatment or having an AIDS-defining event (11
). Others have found that support from family improves compliance (14
). Most patients in the present study lived alone without a steady partner, and although most of them reported to have friends and only few felt lonely, it is possible that a higher degree of support from relatives could be helpful.
Alcohol abuse has previously been reported to be common among HIV patients in Greenland (5
). The present study did not confirm that since only 13% of the patients had a weekly alcohol intake while, although not legalized, hash abuse was relatively common. However, there was an insignificant trend of use of alcohol being associated with poor adherence.
It should, however, be considered that some of the characteristics associated with poor adherence, e.g. low income and alcohol abuse, could actually be results of low compliance and thus progression in HIV disease rather than the opposite. This study is cross-sectional and does not reveal causal associations. To determine such causal relationships longitudinal studies with knowledge of pre-infectious status are needed.
Poor drug-adherence is associated with increased morbidity and mortality (11
) and the low compliance among relatively young patients warrants a special effort for this group. Directly observed therapy (DOT) has been promoted by the WHO to improve adherence to tuberculosis programs and has also been suggested for HIV treatment. However, systematic reviews of randomized trials showed no benefit of this strategy, neither towards tuberculosis (23
) nor towards HIV (24
It is possible that earlier initiation of HAART with newer simplified drug regimens can improve adherence in vulnerable patient groups (25
). In Greenland especially young homosexual men with a high level of sexual activity could be a target for such strategy, and we would thereby not only improve treatment outcome, but also reduce HIV transmission (26