there were 60 registered hiv - positive patients in greenland , most of whom lived in the 2 towns of nuuk and sisimiut ( fig .
hiv patients living in nuuk are treated at the central queen ingrid 's hospital in nuuk , while in the districts hiv treatment and control are guided from queen ingrid 's hospital , but administered by unspecialized local health personnel .
all supervision of hiv patients and initiation of haart are performed by one of the authors ( kl ) .
patients living in nuuk are controlled in the outpatient clinic every 34 months , and in the districts at least twice a year , the latter mainly due to logistic reasons with sample shipping .
blood samples for hiv - rna and cd4 cell counts are sent by courier to denmark .
plasma samples are analysed for hiv - rna at the department of virology , statens serum institut , copenhagen , and cd4 cell count at rigshospitalet , copenhagen . in greenland ,
plasma is assayed for genotypic resistance in all patients at the time of hiv diagnosis and in case of hiv - rna > 1000 copies per ml .
all hiv patients in greenland including data on viral load , cd4 counts , etc . are registered in a central database www.infcarehiv.dk . in this study
virologic failure was defined by 2 repeated hiv rna>200 copies per ml ( 17 ) . to collect data on living conditions and quality of life ,
all known hiv - positive patients were asked to fill in a questionnaire during a routine outpatient visit in the study period 20082009 .
most patients were interviewed or guided by a greenlandic speaking doctor ( mr ) not responsible for the clinical care of the patients .
the questionnaire was a modification of a questionnaire used for a study of 1,212 hiv - positive danes ( 18 ) and comprised questions regarding living conditions and life quality issues .
the modification included questions about inuit ethnicity and specific greenlandic socio - demographic issues . 
inuit  was defined by both parents being born in greenland ,  mixed  when one of the parents was born in greenland and one elsewhere or  of unknown origin  , and as  non - inuit  if none of the parents were known to be born in greenland .
adherence was defined as being seen in the outpatient clinic at least twice a year , and when on haart having taken the last dose of medicine within 24 hours and not having skipped a dose within the last 4 days .
the relative risk of hiv progression measured by high viral load and low cd4 count for non - adherence versus adherence was calculated as the proportion of non - adherent patients with such markers divided by the proportion of adherent patients using a binomial log - linear regression model in proc genmod in sas v9.2 .
the relative risks of non - adherence according to a wide range of living conditions and quality of life markers were calculated in a similar way . when having cells with 0 observations , no rr was estimated and the differences in proportions were evaluated by an exact pearson chi - square test in proc freq in sas . from these univariate analyses a multivariate analysis was carried out by including significant variables ( p<0.05 ) in a single model and then using backward elimination until all remaining factors had reached significance .
the investigation was scientifically and ethically approved by the commission for scientific research in greenland .
patients were informed that their responses remained confidential and would have no consequences for their treatment .
the relative risk of hiv progression measured by high viral load and low cd4 count for non - adherence versus adherence was calculated as the proportion of non - adherent patients with such markers divided by the proportion of adherent patients using a binomial log - linear regression model in proc genmod in sas v9.2 .
the relative risks of non - adherence according to a wide range of living conditions and quality of life markers were calculated in a similar way . when having cells with 0 observations , no rr was estimated and the differences in proportions were evaluated by an exact pearson chi - square test in proc freq in sas . from these univariate analyses a multivariate analysis was carried out by including significant variables ( p<0.05 ) in a single model and then using backward elimination until all remaining factors had reached significance .
the investigation was scientifically and ethically approved by the commission for scientific research in greenland . written informed consent was obtained from all participants .
patients were informed that their responses remained confidential and would have no consequences for their treatment .
forty - six ( 77% ) patients participated in the study , 17 women and 29 men aged 2374 years with a median of 56 years .
virus transmission route was by heterosexual activity in 37 patients ( 80% ) and by men having sex with men ( msm ) activity in 8 ( 17% ) .
the patients had their hiv diagnosis established between 1 and 18 years , median 7 years , prior to the interview .
thirty - seven patients were infected in greenland , the remaining 9 abroad , mostly in denmark .
forty - four of the patients were born in greenland . by the definition used , 43 were inuit , 1 non - inuit and 2 of mixed origin .
forty - one of the patients received treatment with haart , and 5 were untreated .
twenty - five of the participating patients lived in nuuk , and 21 in the districts ( fig .
1 ) . of the non - participating 14 patients , 3 women and 11 men ( median age at diagnosis 55 years , range 3164 years ) ,
3 refused to participate , 3 lived in remote areas , 1 was in jail and 2 failed to attend appointments .
furthermore 5 registered hiv - positive patients had refused treatment and control in the clinic .
these 14 patients had been tested hiv - positive between 2 and 13 years ( median 7 years ) prior to the study .
thirty - one patients ( 67% ) were found to be adherent according to definition .
twenty - nine ( 71% ) of those treated with haart stated that they had taken at least 90% of the prescribed drugs within the last 30 days and none of them had missed a dose within the last 4 days .
there was a significantly higher rate of sufficient virologic response among adherent patients on haart than among non - adherent on haart , and more adherent patients had cd4 cell counts exceeding 350 cells per l ( table i ) .
although overall only 73% had sufficient virologic suppression , almost all ( 97% ) adherent patients had viral loads < 200 copies per ml in contrast to only 17% of non - adherent . 
association between adherence and virologic response to haart and cd4 count among 46 hiv patients from greenland 2008 to 2009 41 patients on haart . 

there was a significant difference in age distribution ( p=0.003 ) with adherent patients being relatively older ( median 58 years , range 4574 ) than non - adherent patients ( median 49 years , range 2360 ) ( fig .
adherence was significantly better among patients living in nuuk than among patients living in the districts outside of nuuk .
fifty percent of those infected through msm activity were non - adherent compared with 27% of heterosexually infected , but the numbers are small and the difference is not significant ( table ii ) .
there was no difference with regard to duration of hiv or of treatment with haart or having an aids - defining event , and no difference with regard to education or financial situation .
regarding quality of life ( table iii ) there was no difference between the 2 groups as to self - perception of health , having a steady partner , or living alone and no difference with regard to having friends or feeling lonely .
there was no difference between the 2 groups with regard to sexual activity or satisfaction , but unsafe sex was significantly more common among non - adherent patients ( table iii ) .
alcohol and tobacco use did not differ significantly among the 2 groups although both showed a trend for association to non - adherence .
it is remarkable that 13 ( 28% ) of the patients abused hash , 3 of them daily ( table iii ) .
association between adherence and socio - demographic and clinical data among 46 hiv patients from greenland 2008 to 2009 note : there may be missing values when the patients refused to answer the question . adjusted for other significant factors . due to convergence problems
/empty cells , no rrs are presented and the p - values presented are from an exact pearson  
  test . due to correlation between the variables  occupation  and  financial support  ,  occupation  was chosen to be included in the multivariate analysis because  financial support  is a subset and thus excludes otherwise valid observations .
association between adherence and life style and quality of life indicators among 46 hiv patients from greenland 2008 to 2009 note : there may be missing values when the patients refused to answer the question . due to few answers not included in the multivariate model , but adjusted for age and place of living . by multivariate analysis , young age and living in a district
as opposed to nuuk were found to be the 2 factors independently associated with poor adherence ( table ii ) . due to few answers unsafe sex
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 .
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 ( 13,1921 ) .
we used a combination of adherence to appointments and to medication , as both are crucial for optimal infection control . according to these criteria
although the results are not directly comparable with other studies ( 10,13,22 ) , 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 ( 19,21 ) .
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 .
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 ) .
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 ) .
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 ( 1113 ) 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 ) .
poor adherence and consequently inferior treatment outcome are common among greenlandic hiv patients , especially in the younger age groups and among patients living in areas outside of the capital nuuk .
the results indicate that close attention should be paid to these groups of hiv patients to improve adherence and reduce hiv - related morbidity and mortality .
 objectivesdespite a high level of sexually transmitted infections , hiv incidence has remained quite stable in greenland with 56 new cases per year ( approximately 10 per 100,000 ) . however , disease control is suboptimal and mortality is relatively high . 
 the aim of the present study was to determine associations between adherence to treatment and treatment outcome , living conditions and quality of life among hiv patients in greenland.material and methodscross - sectional questionnaire - based cohort study of hiv patients in greenland during 20082009 . 
 data regarding treatment , viral load , cd4 count , etc . were obtained from a central hiv-database.resultsforty-six persons , 17 women and 29 men , of the 60 registered hiv - positive patients ( 77% ) were included . 
 eighty percent were heterosexually infected and 17% by men having sex with men ( msm ) activity . 
 median age at the time of diagnosis was 48 years ( range 2063 ) . 
 eighty - nine percent received highly active antiretroviral therapy ( haart ) . 
 sixty - seven percent were adherent as defined by a combination of adherence to appointments and to treatment . 
 ninety - seven percent of adherent and 17% non - adherent patients on haart had hiv - rna less than 200 copies per ml ( rr=24.2 , p<0.0001 ) . 
 poor adherence was associated with younger age ( < 50 years ) ( adjusted rr=7.95 , p=0.005 ) and living in remote areas with no direct contact with skilled personnel ( adjusted rr=6.75 , p=0.01 ) . 
 unsafe sex was also more frequent among non - adherent patients ( rr=4.12 , p=0.026 ) , but due to few answers this topic was not included in the multivariate model.conclusionthe hiv population in greenland is peculiar since most patients are heterosexually infected and middle - aged at diagnosis . a relatively poor adherence and consequently inferior treatment outcome is related to young age and living in remote areas . 
Material and methods
Statistics
Ethics
Results
Discussion
Conclusion
Conflict of interest and funding