**4. Maintain adherence to antiretroviral treatment: perspective of highly adherent patients**

From an individual level, the adherence process requires the interaction of different dimensions. The first dimension covers the beliefs that patients construct about illness and treatment. Patients with high levels of adherence believe that HIV infection acts by replicating the virus within the body and decreasing the defenses, allowing the appearance of symptoms and diseases. In opposition to the beliefs about illness, they consider that HAART stops the virus and allows the defenses to increase, which strengthens the immune system. Although they recognize the benefits of pharmacological treatment, the main cost is the presence of side effects. The short-term effects are perceived as temporary and as indicators of an adaptation of the body. They mainly recognize gastrointestinal symptoms and alterations in mood or perception. Long-term effects are perceived as more damaging, due to their impact on physical appearance, metabolism, internal organs, or sensory and motor alterations [29].

Although the knowledge of common sense about illness can vary according to the cultural context of the patient, its socioeconomic position, or its level of education, it is important to point out that patients need to elaborate a basic explanatory model based on the relationship with health personnel and the education they get about their medical condition. This explanatory model establishes a common basis for collaboration with health services, since it allows to give meaning to care practices and to recognize their own vulnerability. Possibly beliefs about illness contribute to the identification of the threat and susceptibility to HIV infection, while beliefs about treatment favor the identification of the benefits in the care process. A crucial aspect is that the patient evaluates the benefits of the treatment more favorably than the costs of the side effects.

Patients also elaborate beliefs about adherence to treatment. This process is mainly associated with taking the medication, which may imply that greater importance is attached to the pharmacological adherence. This not only reflects the interests of the patient, since in the health services, there is also a greater concern for monitoring medication intake. In addition to taking the medication, patients consider that maintaining adherence requires two fundamental conditions. One of them is responsibility, because becoming a patient involves adopting the discipline of treatment.

to the context of the patient's life but also to develop social interventions and public policies

The identification of facilitators allows health personnel to understand the elements that contribute to the maintenance of good adherence by the patient, whether in the pharmacological or nonpharmacological dimension. The identification of barriers allows health personnel to provide feedback to the patient on those individual, interpersonal, or contextual aspects that limit the treatment and to plan the interventions required to improve the level of adherence (at the individual or collective level). It can even help in the anticipation of relapses, since both the patient and the health personnel can work collaboratively to design and implement strate-

The following section shows how the facilitators interact to promote adherence, from the perspective of highly adherent patients. Likewise, barriers reported by these patients are identified, both for pharmacological and nonpharmacological adherence. This last type of

From an individual level, the adherence process requires the interaction of different dimensions. The first dimension covers the beliefs that patients construct about illness and treatment.

adherence is not usually represented in adherence studies of people living with HIV.

**4. Maintain adherence to antiretroviral treatment: perspective of** 

that benefit the adherence of patients in conditions of greater social vulnerability.

**Figure 2.** Facilitators and barriers to adherence to treatment, at different levels.

gies that reduce the impact of the barriers.

**highly adherent patients**

110 Advances in HIV and AIDS Control

The second condition is that patients maintain the desire to live, instead of "falling emotionally." This refers to the situation in which patients deny or reject the diagnosis, or they are depressed and put their health at risk. Therefore, in order to maintain the medication intake over time, patients need to accept the diagnosis and keep the will to live. Only in this way can patients take responsibility for their own care and incorporate the treatment discipline into their daily life, for a long period of time [29].

To stay under treatment, it is essential that patients anticipate the consequences if they do not adhere. These are the main consequences associated with nonadherence: (1) the treatment will stop working; (2) the virus is going to replicate; (3) the virus is going to become resistant; and (4) the problems will begin, such as the decrease of defenses and the emergence of diseases. It should be noted that the anticipated consequences are consistent with beliefs about illness and treatment. Another aspect that needs to be highlighted is the ability of the adherent patients to take care of themselves, even though the consequences of nonadherence are not visible (such as the replication of the virus or its mutation in resistant strains) or do not occur immediately.

The second dimension of the individual adherence process is affective. It is associated with the meaning they construct about illness, because this is an indicator of the relationship they establish with HIV infection and, in turn, the degree of acceptance of the diagnosis. From the perspective of patients, acceptance of HIV is one of the central conditions for maintaining adherence. There are different types of relationships established by highly adherent patients with their illness. Some consider that HIV infection is a motivation or challenge that drives them to get ahead, that is, a medical condition that acquires a positive meaning because it forces them to fight in life.

• Physical activity. Patients establish an exercise routine or incorporate the activities of their

The Process of Adherence to Treatment in People Living with HIV

http://dx.doi.org/10.5772/intechopen.77032

113

• Rest. The strategies consist of sleeping 7 to 8 hours, not staying up late, and taking naps.

tion becomes occasional, only at parties or celebrations.

• Substance use. Some patients report having quit smoking or drinking (by willpower and not by specialized treatment, especially when there are low levels of previous consumption). In the case of patients who have not stopped drinking, they point out that consump-

• Sexual health. Patients use strategies such as refusing to have sex without a condom, having condoms available, or creating justifications for condom use (such as avoiding pregnancy), especially when there is a difference in power in the couple or they are afraid of being discriminated against because of their medical condition. One facilitator of these practices is the fear of reinfection or contracting another sexually transmitted

• Mental health. Patients resort to strategies such as attending psychological care (individual therapy or self-groups), obtaining social support in the family or in religious groups, and

• Attendance at medical appointments. Strategies were mentioned such as the use of external reminders, saving money to attend the appointment (due to transportation expenses),

• Attendance to laboratory tests. The use of external reminders was pointed out as the only strategy. One aspect that facilitates attendance at appointments is the desire to know the

The adherence process from the perspective of the individual patient involves the interaction between four dimensions. The first dimension comprised beliefs about illness, treatment and adherence. These beliefs require coherence with each other and with the explanatory model of health personnel. To promote adherence at this level, health education is required to provide knowledge on critical aspects of HIV infection. At the same time, it is important that a relationship be established between the patient and the health personnel where the agreement between explanatory models is verified and the dialog is facilitated for the modification of

The second dimension is affective and focuses on the relationship that patients establish with their illness. This is an indicator of the degree of acceptance of HIV infection. Patients will not elaborate the same meaning about illness, as this depends on the psychosocial impact that HIV infection has on their lives. The impact can be diminished by coping strategies and the sources of social support they have to manage the consequences of the medical condition in daily life. It is important not to force the patient to perceive the HIV infection in a certain way; it is necessary to respect his time for acceptance. It is not necessary for the patient to perceive the diagnosis as a transcendental event that has transformed their existence or their identity, but it is a good indicator for adherence when the patient constructs a positive meaning of

"keeping an eye on the appointment," or remembering it internally.

health status, specifically the viral load and the level of CD4 cells.

daily routine as exercise.

disease.

thinking positively.

beliefs that affect the adherence process.

From a more pragmatic stance, there are patients who perceive illness as a "normal" and manageable health condition. In this case, patients normalize HIV infection in their daily lives, but they do not grant it a more transcendental meaning or consider it as a point of transformation of the self. However, they consider that they have some control over the medical condition. Finally, there are patients who conceive HIV infection as an opportunity to change toward a more moderate life. This position seems to make it easier for patients to adopt a healthier lifestyle, but at the same time, it may be linked to a desire to rebuild their social identity [29]. It seems that attributing a positive sense to illness contributes to adherence, regardless of the degree of transcendence granted in the patient's life or the impact on their identity.

In a third dimension, there are the motivational aspects that favor the adherence process. Highly adherent patients indicated three main aspects: (1) loving and taking care of themselves, (2) the family, and (3) the desire to live and "move forward" [29]. These motivational elements are not important only for the beginning of treatment but especially for its long-term maintenance. Adherence can be promoted when patients take care of themselves for the sake of their own well-being or because they want to be well for others. Possibly good adherence is an indicator of psychological well-being and positive relationships in the patient's social environment.

The fourth dimension of adherence is of a practical nature and includes the various actions or strategies that patients carry out to maintain adherence over time. For pharmacological adherence, short-term strategies were identified, such as, the use of external reminders (alarms, notes, diaries, or pillboxes), organizing the medication intake at specific moments of the daily routine, leaving the medication in special places to remember the intake, taking the medication in case of leaving home, reminder of medication intake by relatives, and not stop taking the medication if the schedule was not followed. The short-term strategies are focused on avoiding forgetfulness, which is the main barrier to pharmacological adherence even in highly adherent patients. In the long term, taking the medication is easier because it becomes a habit and is remembered mentally. There are also other strategies such as adapting to side effects and having willpower, which, unlike the previous strategies, seem to be more idiosyncratic and linked to stoicism [29, 30].

Regarding nonpharmacological adherence, patients indicated strategies according to each area of health care [29, 30]:

• Diet. Their strategies are to avoid harmful foods and try to eat healthy foods (low in fat and carbohydrates, high in vitamins and minerals).

• Physical activity. Patients establish an exercise routine or incorporate the activities of their daily routine as exercise.

The second dimension of the individual adherence process is affective. It is associated with the meaning they construct about illness, because this is an indicator of the relationship they establish with HIV infection and, in turn, the degree of acceptance of the diagnosis. From the perspective of patients, acceptance of HIV is one of the central conditions for maintaining adherence. There are different types of relationships established by highly adherent patients with their illness. Some consider that HIV infection is a motivation or challenge that drives them to get ahead, that is, a medical condition that acquires a positive meaning because it

From a more pragmatic stance, there are patients who perceive illness as a "normal" and manageable health condition. In this case, patients normalize HIV infection in their daily lives, but they do not grant it a more transcendental meaning or consider it as a point of transformation of the self. However, they consider that they have some control over the medical condition. Finally, there are patients who conceive HIV infection as an opportunity to change toward a more moderate life. This position seems to make it easier for patients to adopt a healthier lifestyle, but at the same time, it may be linked to a desire to rebuild their social identity [29]. It seems that attributing a positive sense to illness contributes to adherence, regardless of the

degree of transcendence granted in the patient's life or the impact on their identity.

In a third dimension, there are the motivational aspects that favor the adherence process. Highly adherent patients indicated three main aspects: (1) loving and taking care of themselves, (2) the family, and (3) the desire to live and "move forward" [29]. These motivational elements are not important only for the beginning of treatment but especially for its long-term maintenance. Adherence can be promoted when patients take care of themselves for the sake of their own well-being or because they want to be well for others. Possibly good adherence is an indicator of psychological well-being and positive relationships in the patient's social environment.

The fourth dimension of adherence is of a practical nature and includes the various actions or strategies that patients carry out to maintain adherence over time. For pharmacological adherence, short-term strategies were identified, such as, the use of external reminders (alarms, notes, diaries, or pillboxes), organizing the medication intake at specific moments of the daily routine, leaving the medication in special places to remember the intake, taking the medication in case of leaving home, reminder of medication intake by relatives, and not stop taking the medication if the schedule was not followed. The short-term strategies are focused on avoiding forgetfulness, which is the main barrier to pharmacological adherence even in highly adherent patients. In the long term, taking the medication is easier because it becomes a habit and is remembered mentally. There are also other strategies such as adapting to side effects and having willpower, which, unlike the previous strategies, seem to be more idiosyn-

Regarding nonpharmacological adherence, patients indicated strategies according to each

• Diet. Their strategies are to avoid harmful foods and try to eat healthy foods (low in fat and

forces them to fight in life.

112 Advances in HIV and AIDS Control

cratic and linked to stoicism [29, 30].

carbohydrates, high in vitamins and minerals).

area of health care [29, 30]:


The adherence process from the perspective of the individual patient involves the interaction between four dimensions. The first dimension comprised beliefs about illness, treatment and adherence. These beliefs require coherence with each other and with the explanatory model of health personnel. To promote adherence at this level, health education is required to provide knowledge on critical aspects of HIV infection. At the same time, it is important that a relationship be established between the patient and the health personnel where the agreement between explanatory models is verified and the dialog is facilitated for the modification of beliefs that affect the adherence process.

The second dimension is affective and focuses on the relationship that patients establish with their illness. This is an indicator of the degree of acceptance of HIV infection. Patients will not elaborate the same meaning about illness, as this depends on the psychosocial impact that HIV infection has on their lives. The impact can be diminished by coping strategies and the sources of social support they have to manage the consequences of the medical condition in daily life. It is important not to force the patient to perceive the HIV infection in a certain way; it is necessary to respect his time for acceptance. It is not necessary for the patient to perceive the diagnosis as a transcendental event that has transformed their existence or their identity, but it is a good indicator for adherence when the patient constructs a positive meaning of illness and considers it a manageable condition. Although the meaning of illness is elaborated over time, its acceptance can be promoted through individual therapy. Especially useful are the support groups, because the construction of new discourses about living with HIV is promoted within the framework of these social relations.

The third dimension is motivational and consists of identifying those elements that encourage the patient to start treatment but, above all, maintain adherence in the long term. The main sources of motivation are individual (like the desire to continue living and taking care of oneself) and interpersonal (taking care of oneself to be well for others). Both sources are important and complement each other, but individual motivations should be emphasized, especially when patients have scarce social networks or persistent conflicts exist in their social network. Individual or group psychotherapy can strengthen individual motivation, but it is also necessary to take into account the role of social support from family members, friends, or the couple in patient care to promote interpersonal motivation. It is worth mentioning that other possible motivations that can be explored with patients are future goals or plans, since self-care is strengthened when there is a specific purpose that is to be achieved in the short, medium, or long terms.

The fourth dimension is practical and includes strategies for the two types of adherence. The strategies for pharmacological adherence are mainly focused on remembering the medication, so they can be promoted from health education, by behavioral modeling of strategies by health personnel, or through social learning in support groups. Another aspect that needs to be addressed is the management of side effects of treatment, which implies a close dialog with the health personnel for the monitoring of side effects, to assess whether the patient can benefit from medications to reduce side effects or if a change in the treatment scheme is required.

• Diet. The individual barrier is the difficulty in leaving junk food. The contextual barrier is

The Process of Adherence to Treatment in People Living with HIV

http://dx.doi.org/10.5772/intechopen.77032

115

• Physical activity. The main individual barrier is feeling weak or tired. The contextual bar-

• Rest. The most frequently mentioned individual barrier was physical discomfort. The main

• Substance use. The individual barriers identified were tobacco addiction and not attending specialized help to quit smoking. The contextual barriers identified were friendships that

• Sexual health. The barriers were identified in the context of the couple relationship. Some mentioned that at certain times they did not use the condom because they did not care about risk. Also mentioned was the avoidance of sexual relations with a stable partner due

• Mental health. Depression and stigma were the main barriers to mental health. A situation mentioned by some patients was the rejection of psychological services or the desire to get

• Attendance at medical appointments. The individual barriers were forgetfulness and physical discomfort. The main contextual barriers were work and not having money for

the economic difficulty to buy healthy foods.

**Figure 3.** Dimensions of the adherence process at the individual level.

contextual barrier was the work schedule.

rier is the lack of time to exercise.

consume substances.

ahead by themselves.

transportation.

to the fear of transmitting HIV.

Strategies for nonpharmacological adherence can also be promoted from health education, individual counseling, or support groups. In each area of health care, it is necessary to monitor the patient's behavior to establish minimum goals and to evaluate the follow-up of health recommendations. In areas where difficulties are detected, problem-solving therapy can be used to address the barriers that limit health care and prevent relapse. In case the difficulties are maintained, it is necessary to channel the patient with specialized personnel in each area, such as nutritionists, psychotherapists specialized in addictions, or self-support groups (**Figure 3**).

Different barriers may appear through the adherence process, either individual or contextual. For pharmacological adherence, the following individual barriers have been identified: forgetfulness of medicine intake, physical discomfort, side effects, and emotional distress. It should be noted that patients' emotional distress is not only linked to their biography and personality; it is a suffering with a social origin, because it is linked to stigma and discrimination processes. As contextual barriers were mentioned, the pending tasks in the domestic or work environment that interfere with medication intake. The barriers to nonpharmacological adherence for each area of health care are the following [29, 30]:

**Figure 3.** Dimensions of the adherence process at the individual level.

illness and considers it a manageable condition. Although the meaning of illness is elaborated over time, its acceptance can be promoted through individual therapy. Especially useful are the support groups, because the construction of new discourses about living with HIV is pro-

The third dimension is motivational and consists of identifying those elements that encourage the patient to start treatment but, above all, maintain adherence in the long term. The main sources of motivation are individual (like the desire to continue living and taking care of oneself) and interpersonal (taking care of oneself to be well for others). Both sources are important and complement each other, but individual motivations should be emphasized, especially when patients have scarce social networks or persistent conflicts exist in their social network. Individual or group psychotherapy can strengthen individual motivation, but it is also necessary to take into account the role of social support from family members, friends, or the couple in patient care to promote interpersonal motivation. It is worth mentioning that other possible motivations that can be explored with patients are future goals or plans, since self-care is strengthened when there is a specific purpose that is to be achieved in the short,

The fourth dimension is practical and includes strategies for the two types of adherence. The strategies for pharmacological adherence are mainly focused on remembering the medication, so they can be promoted from health education, by behavioral modeling of strategies by health personnel, or through social learning in support groups. Another aspect that needs to be addressed is the management of side effects of treatment, which implies a close dialog with the health personnel for the monitoring of side effects, to assess whether the patient can benefit from medications to reduce side effects or if a change in the treatment scheme is

Strategies for nonpharmacological adherence can also be promoted from health education, individual counseling, or support groups. In each area of health care, it is necessary to monitor the patient's behavior to establish minimum goals and to evaluate the follow-up of health recommendations. In areas where difficulties are detected, problem-solving therapy can be used to address the barriers that limit health care and prevent relapse. In case the difficulties are maintained, it is necessary to channel the patient with specialized personnel in each area, such as nutritionists, psychotherapists specialized in addictions, or self-support groups

Different barriers may appear through the adherence process, either individual or contextual. For pharmacological adherence, the following individual barriers have been identified: forgetfulness of medicine intake, physical discomfort, side effects, and emotional distress. It should be noted that patients' emotional distress is not only linked to their biography and personality; it is a suffering with a social origin, because it is linked to stigma and discrimination processes. As contextual barriers were mentioned, the pending tasks in the domestic or work environment that interfere with medication intake. The barriers to nonpharmacological

adherence for each area of health care are the following [29, 30]:

moted within the framework of these social relations.

medium, or long terms.

114 Advances in HIV and AIDS Control

required.

(**Figure 3**).


• Attendance to laboratory tests. The barrier identified was forgetfulness. It should be mentioned that laboratory studies are performed less frequently than medical appointments.

that the patient can accept the illness and emotionally prepare to maintain adherence. A problem is that in health services, care is not usually promoted in an integral way, but mainly physical health care is considered and mental health is not sufficiently attended. Another difficulty lies in the rejection of patients to psychological care, either because of the stigma toward

The Process of Adherence to Treatment in People Living with HIV

http://dx.doi.org/10.5772/intechopen.77032

117

Finally, attendance at medical appointments or laboratory tests is often affected by forgetfulness. Reminders via telephone, text message, or social networks can be useful to promote adherence in this area. Some patients pointed to work as a barrier, which can be reduced if health centers establish a policy for extending the schedules of service. Physical discomfort can be a barrier when a health problem makes it difficult to attend the health center, so they can benefit from special procedures for changing appointments in such circumstances. Certain patients' report has economic difficulties for transport payment. In certain vulnerable groups, financial support may be granted for attendance at medical appointments (**Figure 4**).

Adherence is a process that develops over time, where people living with HIV need to identify as patients, take an active role in their health care, and establish a collaborative relationship with health personnel. The agency capacity is not the same for all patients; it depends on their level of social vulnerability. This means that there are structural conditions that reduce the capacity of agency and the options of patients in their daily lives. Patients are not only rational subjects who make decisions regarding treatment based on a cost–benefit analysis;

**Figure 4.** Individual and contextual barriers during the adherence process.

mental illness or the desire to solve their psychosocial problems individually.

**5. Conclusions**

Diet is affected not only by the habits developed in the past by the patient but also by the influence of culture on food preferences, the supply of healthy food in its sociocultural context, and feeding practices in the family. It is therefore essential that overweight and obese patients can attend a nutritional consultation to continuously monitor their weight and develop a meal plan that fits their daily routine and economic capacity.

Physical activity and rest are two areas of health care closely linked to the work context and the demands of home. The overload of daily tasks can reduce the time available for rest and exercise. If the patient cannot access a job with better conditions for their health, it is important to focus on the organization of time to get more rest hours and design a physical activity plan that adapts to the patient's daily routine and can be performed in a short time.

Substance use is an area that requires greater attention in health services. Tobacco addiction is usually minimized, and specialized care services are not frequently visited for treatment. The consumption of alcohol can be difficult to avoid in a sociocultural context where it is promoted as a ritual of socialization, which is why in health services a compromise solution is usually established: allow the patient to consume alcohol occasionally during special situations. However, health services need to send a clear message to patients regarding substance use during treatment. It is necessary for health personnel to identify the level of substance use in the patient, clearly communicate the consequences of consumption for their health and the treatment process, and conduct referral to specialized services in addiction care when required.

In the area of sexual health, adherent patients usually adopt condom use in a systematic way. However, the problems can be due to a tiredness of the use of the condom, because they perceive it as a routine act, which affects spontaneity and eroticism. These situations are not usually reported to health personnel, so it is necessary to establish a trust relationship with the patient so that they can talk about these issues and request help when necessary. In the care services, interventions that address the eroticization of condom use can be implemented.

Especially, it is necessary to be alert when patients are immersed in power relations where the negotiation of condom use is limited. On the other hand, some patients report that they have stopped having sex for fear of transmitting HIV. In these cases, it may be necessary to provide relevant information about transmission risks and protected sex practices. Counseling sessions for the couple can also be developed to clarify doubts about the transmission of HIV and provide alternatives for safe sex and protected sex.

The mental health of patients can be compromised from the moment of diagnosis, because it generates emotional distress and limits the acceptance of HIV. This is due not only to a patient's vulnerability in psychological terms but also because of the social vulnerability associated with their socioeconomic position and the processes of stigma and discrimination. Psychological care (at the individual or group level) is essential before starting treatment so that the patient can accept the illness and emotionally prepare to maintain adherence. A problem is that in health services, care is not usually promoted in an integral way, but mainly physical health care is considered and mental health is not sufficiently attended. Another difficulty lies in the rejection of patients to psychological care, either because of the stigma toward mental illness or the desire to solve their psychosocial problems individually.

Finally, attendance at medical appointments or laboratory tests is often affected by forgetfulness. Reminders via telephone, text message, or social networks can be useful to promote adherence in this area. Some patients pointed to work as a barrier, which can be reduced if health centers establish a policy for extending the schedules of service. Physical discomfort can be a barrier when a health problem makes it difficult to attend the health center, so they can benefit from special procedures for changing appointments in such circumstances. Certain patients' report has economic difficulties for transport payment. In certain vulnerable groups, financial support may be granted for attendance at medical appointments (**Figure 4**).

**Figure 4.** Individual and contextual barriers during the adherence process.

## **5. Conclusions**

• Attendance to laboratory tests. The barrier identified was forgetfulness. It should be mentioned that laboratory studies are performed less frequently than medical

Diet is affected not only by the habits developed in the past by the patient but also by the influence of culture on food preferences, the supply of healthy food in its sociocultural context, and feeding practices in the family. It is therefore essential that overweight and obese patients can attend a nutritional consultation to continuously monitor their weight and develop a meal

Physical activity and rest are two areas of health care closely linked to the work context and the demands of home. The overload of daily tasks can reduce the time available for rest and exercise. If the patient cannot access a job with better conditions for their health, it is important to focus on the organization of time to get more rest hours and design a physical activity

Substance use is an area that requires greater attention in health services. Tobacco addiction is usually minimized, and specialized care services are not frequently visited for treatment. The consumption of alcohol can be difficult to avoid in a sociocultural context where it is promoted as a ritual of socialization, which is why in health services a compromise solution is usually established: allow the patient to consume alcohol occasionally during special situations. However, health services need to send a clear message to patients regarding substance use during treatment. It is necessary for health personnel to identify the level of substance use in the patient, clearly communicate the consequences of consumption for their health and the treatment process, and conduct referral to specialized services in addiction

In the area of sexual health, adherent patients usually adopt condom use in a systematic way. However, the problems can be due to a tiredness of the use of the condom, because they perceive it as a routine act, which affects spontaneity and eroticism. These situations are not usually reported to health personnel, so it is necessary to establish a trust relationship with the patient so that they can talk about these issues and request help when necessary. In the care services, interventions that address the eroticization of condom use can be implemented. Especially, it is necessary to be alert when patients are immersed in power relations where the negotiation of condom use is limited. On the other hand, some patients report that they have stopped having sex for fear of transmitting HIV. In these cases, it may be necessary to provide relevant information about transmission risks and protected sex practices. Counseling sessions for the couple can also be developed to clarify doubts about the transmission of HIV and

The mental health of patients can be compromised from the moment of diagnosis, because it generates emotional distress and limits the acceptance of HIV. This is due not only to a patient's vulnerability in psychological terms but also because of the social vulnerability associated with their socioeconomic position and the processes of stigma and discrimination. Psychological care (at the individual or group level) is essential before starting treatment so

plan that adapts to the patient's daily routine and can be performed in a short time.

plan that fits their daily routine and economic capacity.

provide alternatives for safe sex and protected sex.

appointments.

116 Advances in HIV and AIDS Control

care when required.

Adherence is a process that develops over time, where people living with HIV need to identify as patients, take an active role in their health care, and establish a collaborative relationship with health personnel. The agency capacity is not the same for all patients; it depends on their level of social vulnerability. This means that there are structural conditions that reduce the capacity of agency and the options of patients in their daily lives. Patients are not only rational subjects who make decisions regarding treatment based on a cost–benefit analysis; they are at the same time affective subjects who need to deal with the rupture of their social world caused by a medical condition that is stigmatized in his cultural context.

[5] Chesney M, Morin M, Sherr L. Adherence to HIV combination therapy. Social Science &

The Process of Adherence to Treatment in People Living with HIV

http://dx.doi.org/10.5772/intechopen.77032

119

[6] Menéndez EL. De sujetos, saberes y estructuras. Lugar Editorial: Buenos Aires,

[7] Aggleton P, Parker R. Documento de trabajo no. 9. Estigma y discriminación relacionados con el VIH/SIDA: un marco conceptual e implicaciones para la acción. México: El

[8] Almanza A. Narrativas acerca del VIH: la mirada del paciente y de su red social. Saar-

[9] Spire B, Duran S, Souville M, Leport C, Raffi F, Moatti JP. The APROCO cohort study group. Adherence to highly active antiretroviral therapies (HAART) in HIV-infected patients: from a predictive to a dynamic approach. Social Science & Medicine. 2002;

[10] Norton W, Rivet K, Fisher W, Shuper P, Ferrer R, Cornman D, Trayling C, Reeding C, Fisher J. Information-motivation-behavioral skills barriers associated with intentional versus unintentional ARV non-adherence behavior among HIV+ patients in clinical care.

[11] Applebaum A, Richardson M, Brady S, Brief D, Keane T. Gender and other psychosocial factors as predictors of adherence to highly active antiretroviral therapy (HAART) in adults with comorbid HIV/AIDS, psychiatric and substance-related disorder. AIDS and

[12] Mo P, Mak W. Intentionality of medication non-adherence among individuals living

[13] Puskas C, Forrest J, Parashar S, Salters K, Cescon A, Kaida A, Miller C, Bangsberg D, Hogg R. Women and vulnerability to HAART non-adherence: A literature review of treatment adherence by gender from 2000 to 2011. Current HIV/AIDS Reports. 2011;**8**:277-287 [14] Ubbiali A, Donati D, Chiorri C, Bregani V, Cattaneo E, Maffei C, Visintini R. Prediction of adherence to antiretroviral therapy: Can patients´ gender play some role? An italian

[15] Gagné C, Godin G. Improving self-report measures of non-adherence to HIV medica-

[16] Balandrán D, Gutiérrez J, Romero M. Evaluación de la adherencia antirretroviral en México: adherencia de cuatro días vs índice de adherencia. Revista de Investigación

[17] Murphy D, Johnston K, Martin D, Marelich W, Hoffman D. Barriers to antiretroviral adherence among HIV-infected adults. In: Laurence J, editor. Medication adherence in

[18] Good B. Medicina, racionalidad y experiencia. Una perspectiva antropológica. Barcelona:

with HIV/AIDS in Hong Kong. AIDS Care. 2009;**21**(6):785-795

pilot study. AIDS Care. 2008;**20**(5):571-575

tions. Psychology and Health. 2005;**20**(6):803-816

HIV/AIDS. Nueva York: Mary Ann Liebert Publishers; 2004

Medicine. 2000;**50**(11):1599-1605

Argentina; 2009

Colegio de México; 2002

brücken: Publicia; 2015

AIDS Care. 2010;**22**(8):979-987

Behavior. 2008;**13**:60-65

Clínica. 2013;**65**(5):384-391

Bellaterra; 2003

**54**(10):1481-1496

Adherence has two dimensions: pharmacological and nonpharmacological. At any time in the adherence process, patients may become nonadherent, in one or both dimensions. The patterns of nonadherence can be generated in the short, medium, and long terms; persistent patterns that extend over time are more problematic. From the perspective of the individual patient, adherence is maintained at any point of time due to the interaction of the following elements: beliefs about illness, treatment and adherence, affection toward HIV infection, motivations, and strategies for taking medication and health care. However, the patient may encounter individual and contextual barriers in multiple areas: medication intake, diet, rest, physical activity, substance use, sexual health, mental health, attendance at medical appointments, and attendance to laboratory tests. Health services require a comprehensive evaluation of the patient in each of the areas indicated, in order to understand the resources available to the patient for adherence and the barriers that require specific interventions.
