**3. Facilitators and barriers to adherence to treatment in people living with HIV**

In the literature, several factors associated with adherence to treatment have been reported. A series of studies have identified the following factors based on cross-sectional studies, from the perspective of the researchers [19]:

• Factors related to personal attributes. They include the patient's clinical status, educational level, income, access to housing, and stability of the home.

• Factors related to the treatment regimen. It has been found that adherence is affected by the complexity of the regimen (depending on the number of pills or the type of indications for taking the medication), the ease of adapting the treatment to daily life, the use of devices for adherence (such as pillboxes or alarms), or side effects of treatment.

sources of social support and the maintenance of a collaborative relationship with health

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As has happened with the facilitators, the main barriers have been identified at the individual level. Adherence is affected by beliefs about antiretroviral treatment, lack of information about treatment, beliefs about illness, as well as minimizing the risks of living with HIV. It is also affected by aspects associated with the patient's physical condition, such as forgetfulness, fatigue, or feeling sick. Even self-care can be neglected when the patient perceives a good health status. At the affective level, adherence is limited by the emotional impact of diagnosis, lack of acceptance, or rejection of treatment because it remembers the presence of HIV. Other aspects that hinder adherence are the fatigue of medication, anger, depression, despair, or

The barriers to adherence associated with the patient's context are the interference of treatment with the daily routine, the changes in the routine, and the workload or being out of home during the moment of medicine intake. At the interpersonal level, adherence is limited by the lack of social support and conflicts in the relationship with health personnel [20, 22, 25]. There are also barriers linked to social inequality. Some are of an economic nature, such as the difficulty to cover the expenses required for transportation to medical appointments or to maintain an appropriate diet [23, 24]. Other barriers are related to the internalization of stigma and the fear of discrimination. There are also barriers associated with gender inequality, such as differences in access to medical services and treatment or in the negotiation of condom use, especially when the couple denies the diagnosis of HIV [28]. Men may reject

In the previous section, it was mentioned that at any time during the treatment process, the patient faces the dilemma of adhering or not adhering. Adherence involves both taking the medication according to the specified conditions and adopting a healthy lifestyle in multiple areas. It should be added that at each moment of the treatment process, the patient encounters

At the individual level, there are facilitators and barriers of different types: physical, cognitive, affective, motivational, and practical. Traditionally, health psychology has focused on modifying these elements to promote adherence. However, there are also facilitators and barriers at the interpersonal level, specifically linked to social relationships established in areas such as family, friends, health services, or the community. At this level, different types of interventions are required: family interventions, interventions focused on providing social support or expanding the patient's network, interventions focused on improving interaction with health personnel, and interventions to modify the organization of health

Finally, there are facilitators and barriers that are part of the patient's life context: daily routines, work and home conditions, and economic conditions. There are also conditions that can limit access and permanence in health services, such as gender inequality and social processes of stigma and discrimination. This level needs to be considered not only to adjust the treatment

personnel [20–26].

services.

other vital concerns beyond health [23–27].

adherence as a form of resistance to "body discipline" [26].

multiple facilitators and barriers to adherence (**Figure 2**).


In another series of studies based on qualitative methods, facilitators and barriers to adherence have been identified from the perspective of people living with HIV. A facilitator is any individual attribute (physical, cognitive, emotional, or behavioral), characteristic of treatment, interpersonal process, or contextual aspect that favors the adherence process. In opposition, a barrier is the individual attribute, characteristic of treatment, interpersonal process, or contextual aspect that limits the adherence process.

At the individual level, beliefs that facilitate adherence have been found, such as the recognition of the drug's role in the prevention of death and illness, the perception of medicine as responsible for the improvement of health and well-being, the establishment of the maintenance of health as a priority, and religious beliefs. At an affective and motivational level, adherence is facilitated by the fear of experiencing opportunistic infections or hospitalizations, getting used to the presence of side effects, the emotional work of appropriating the suffering and feeling pride in their coping, having incentives as significant persons or future plans, adopting an optimistic perspective toward the future, or the will to live [20–25].

Other aspects that influence adherence are related to the impact of treatment, such as the absence of side effects or the clinical results of treatment. Among the practices that promote adherence are the use of external reminders, taking the medicine when the patient needs to leave the home, dealing with side effects, self-monitoring of symptoms and energy level, and conducting laboratory studies. Over time, taking the medication becomes a habit that is performed automatically [20–25].

Among the contextual aspects that facilitate adherence are having a stable lifestyle, the inclusion of treatment in the lifestyle, and the association of medication intake with daily routines. At the interpersonal level, there are facilitators such as access to positive sources of social support and the maintenance of a collaborative relationship with health personnel [20–26].

• Factors related to the treatment regimen. It has been found that adherence is affected by the complexity of the regimen (depending on the number of pills or the type of indications for taking the medication), the ease of adapting the treatment to daily life, the use of devices

• Psychological factors. This level includes cognitive aspects such as concentration difficulties or forgetting, understanding of the role of antiretroviral treatment, or knowledge about the medical condition. Attitudes toward illness, treatment, and medications are also considered. Negative mental health factors include depression, hopelessness, anxiety or other types of psychiatric morbidity, alcohol or drug use, and coping through avoidance strategies. Positive factors include a positive attitude toward the future, long-term plans and

• Social factors. The relationship with the health service provider, the social support available, and the fear of revealing the diagnosis (linked to social processes of stigma and dis-

• Structural factors. It includes access to treatment and health services, also economic re-

In another series of studies based on qualitative methods, facilitators and barriers to adherence have been identified from the perspective of people living with HIV. A facilitator is any individual attribute (physical, cognitive, emotional, or behavioral), characteristic of treatment, interpersonal process, or contextual aspect that favors the adherence process. In opposition, a barrier is the individual attribute, characteristic of treatment, interpersonal process, or con-

At the individual level, beliefs that facilitate adherence have been found, such as the recognition of the drug's role in the prevention of death and illness, the perception of medicine as responsible for the improvement of health and well-being, the establishment of the maintenance of health as a priority, and religious beliefs. At an affective and motivational level, adherence is facilitated by the fear of experiencing opportunistic infections or hospitalizations, getting used to the presence of side effects, the emotional work of appropriating the suffering and feeling pride in their coping, having incentives as significant persons or future

plans, adopting an optimistic perspective toward the future, or the will to live [20–25].

Other aspects that influence adherence are related to the impact of treatment, such as the absence of side effects or the clinical results of treatment. Among the practices that promote adherence are the use of external reminders, taking the medicine when the patient needs to leave the home, dealing with side effects, self-monitoring of symptoms and energy level, and conducting laboratory studies. Over time, taking the medication becomes a habit that is per-

Among the contextual aspects that facilitate adherence are having a stable lifestyle, the inclusion of treatment in the lifestyle, and the association of medication intake with daily routines. At the interpersonal level, there are facilitators such as access to positive

for adherence (such as pillboxes or alarms), or side effects of treatment.

goals, active coping, and stable mental health.

textual aspect that limits the adherence process.

crimination) have been identified.

sources to stay in treatment.

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formed automatically [20–25].

As has happened with the facilitators, the main barriers have been identified at the individual level. Adherence is affected by beliefs about antiretroviral treatment, lack of information about treatment, beliefs about illness, as well as minimizing the risks of living with HIV. It is also affected by aspects associated with the patient's physical condition, such as forgetfulness, fatigue, or feeling sick. Even self-care can be neglected when the patient perceives a good health status. At the affective level, adherence is limited by the emotional impact of diagnosis, lack of acceptance, or rejection of treatment because it remembers the presence of HIV. Other aspects that hinder adherence are the fatigue of medication, anger, depression, despair, or other vital concerns beyond health [23–27].

The barriers to adherence associated with the patient's context are the interference of treatment with the daily routine, the changes in the routine, and the workload or being out of home during the moment of medicine intake. At the interpersonal level, adherence is limited by the lack of social support and conflicts in the relationship with health personnel [20, 22, 25]. There are also barriers linked to social inequality. Some are of an economic nature, such as the difficulty to cover the expenses required for transportation to medical appointments or to maintain an appropriate diet [23, 24]. Other barriers are related to the internalization of stigma and the fear of discrimination. There are also barriers associated with gender inequality, such as differences in access to medical services and treatment or in the negotiation of condom use, especially when the couple denies the diagnosis of HIV [28]. Men may reject adherence as a form of resistance to "body discipline" [26].

In the previous section, it was mentioned that at any time during the treatment process, the patient faces the dilemma of adhering or not adhering. Adherence involves both taking the medication according to the specified conditions and adopting a healthy lifestyle in multiple areas. It should be added that at each moment of the treatment process, the patient encounters multiple facilitators and barriers to adherence (**Figure 2**).

At the individual level, there are facilitators and barriers of different types: physical, cognitive, affective, motivational, and practical. Traditionally, health psychology has focused on modifying these elements to promote adherence. However, there are also facilitators and barriers at the interpersonal level, specifically linked to social relationships established in areas such as family, friends, health services, or the community. At this level, different types of interventions are required: family interventions, interventions focused on providing social support or expanding the patient's network, interventions focused on improving interaction with health personnel, and interventions to modify the organization of health services.

Finally, there are facilitators and barriers that are part of the patient's life context: daily routines, work and home conditions, and economic conditions. There are also conditions that can limit access and permanence in health services, such as gender inequality and social processes of stigma and discrimination. This level needs to be considered not only to adjust the 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 physi-

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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

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

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

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

cal appearance, metabolism, internal organs, or sensory and motor alterations [29].

the costs of the side effects.

discipline of treatment.

not occur immediately.

their daily life, for a long period of time [29].

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

to the context of the patient's life but also to develop social interventions and public policies that benefit the adherence of patients in conditions of greater social vulnerability.

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 strategies that reduce the impact of the barriers.

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