**2. Perspectives on adherence**

The social construction of adherence influences the way in which patients are constituted as subjects, the type of relationships they establish with health personnel, and the policies of health services for patient care. Previously the term "compliance" was used to refer to the degree to which the patient followed medical recommendations for taking the medication or making lifestyle changes. The concept was criticized because it assumed a hierarchical relationship between the doctor and the patient, considered that the medical recommendations were correct and that the failure in the treatment was mainly the responsibility of the patient for not complying with the recommendations [5].

In contrast, the concept of adherence emerged in a historical moment where patients had greater access to information technologies, which expanded the possibilities of having information about their diagnosis and treatment. This allowed patients to develop a sense of agency, establish a dialog with health personnel and adopt a critical stance during the treatment process. Likewise, the emergence of chronic conditions sets limits to the power of health personnel and forced the incorporation of the patient in the planning and maintenance of long-term care.

Adherence means a different type of relationship to "compliance": a horizontal, democratic, and collaborative relationship for the maintenance of care over time. The concept not only implies a change in the relationship with health personnel; it also represents a change in the subject: the patient becomes an active agent in the treatment process. Health services not only attribute responsibility to the patient for taking the medication or following the health recommendations; they also encourage the patient to request information about their health status and to participate in decision-making during treatment. It should be noted that this notion of the patient is based on two assumptions: care depends on the patient's will, and the patient is interested in maintaining or improving their health status.

in access to services that allow maintaining care over time as food, education, health, housing, employment, and transportation, among others. For this reason, public health cannot be limited to a "pharmaceuticalization" or exclusive emphasis on access to medication, but it requires considering the social and economic conditions that affect the possibilities of patients

The second challenge, which is addressed in this chapter, is the promotion of adherence to treatment in people living with HIV. This challenge is linked to the facilitation of psychosocial processes that allow long-term adherence, while the previous challenge focuses mainly on the structural conditions associated with adherence. Unlike pharmacological treatment for other medical conditions, HAART requires an efficacy greater than 95% to control the number of copies of the virus in the body. The suboptimal medication intake is associated with higher levels of morbidity and mortality as well as the emergence of drug-resistant viral strains. This

The lack of adherence to treatment has multiple consequences for the state: increased expenses for hospitalization, care for opportunistic infections, and changes in treatment schemes and laboratory studies. In turn, lack of adherence increases the risk of HIV transmission in popu-

The study of adherence to treatment in people living with HIV has focused mainly on pharmacological adherence. It is necessary to develop a comprehensive perspective on adherence, which not only includes medication intake but also the adoption of a healthy lifestyle in multiple areas. The following section analyzes the concept of adherence and its influence on the

The social construction of adherence influences the way in which patients are constituted as subjects, the type of relationships they establish with health personnel, and the policies of health services for patient care. Previously the term "compliance" was used to refer to the degree to which the patient followed medical recommendations for taking the medication or making lifestyle changes. The concept was criticized because it assumed a hierarchical relationship between the doctor and the patient, considered that the medical recommendations were correct and that the failure in the treatment was mainly the responsibility of the patient

In contrast, the concept of adherence emerged in a historical moment where patients had greater access to information technologies, which expanded the possibilities of having information about their diagnosis and treatment. This allowed patients to develop a sense of agency, establish a dialog with health personnel and adopt a critical stance during the treatment process. Likewise, the emergence of chronic conditions sets limits to the power of health personnel and forced the incorporation of the patient in the planning and maintenance of

to maintain a long-term pharmacological treatment [2].

104 Advances in HIV and AIDS Control

reduces the effectiveness of subsequent treatment schemes [3].

patient's relationship with health services.

for not complying with the recommendations [5].

**2. Perspectives on adherence**

long-term care.

lations and the development of new strains resistant to treatment [4].

From biomedical discourse, it is assumed that subjects are able to choose; act rationally, intentionally, and responsibly; and make decisions in terms of costs and benefits. However, the possibility of deciding is determined structurally. This means that the subjects are not completely free to decide; they can select the possibilities available for their local context, according to their socioeconomic position and the dominant cultural values [6]. As previously mentioned, social inequality not only affects access to treatment; it also limits access to services that favor the maintenance of care and the patient's ability to become adherent.

In the particular case of HIV infection, there are two additional elements that affect the development of adherence. The social processes of stigma and discrimination [7] contribute to the exclusion of patients from health services, the delay in diagnosis, the rejection of the medical condition and treatment, the concealment of the diagnosis, and the reduction of social support. Close connection with these processes is the emotional discomfort, because the suffering caused by knowing the serological status can manifest itself in rejection toward diagnosis and health services; the development of risk practices or the appearance of a psychological disorder that limits the capacity for health care [8].

While it is important to consider that adherence requires an active agent in their self-care that maintains a collaborative relationship with health services, it is also assumed that the patient's agency is limited. There are different possibilities for patients to become adherents, due to structural inequalities, the processes of stigma and discrimination, and the emotional distress generated by the HIV diagnosis. Therefore, adherence is not a state that is achieved by all patients at the same time.

It is more appropriate to consider adherence as a dynamic process that develops over time [9], influenced by the social, economic, and cultural context surrounding the patient. Adherence is also affected by the learning process that arises from the patient's personal experience with diagnosis and treatment. This means that people living with HIV have different temporalities and rhythms to become adherent patients. Adherence is not a state that is reached once and for all, but a process that must be continually updated. At any point in treatment, the patient can become nonadherent, either intentionally or involuntarily [10].

From an integral perspective of patient care, it is assumed that there are two complementary dimensions of adherence. The first dimension is pharmacological adherence, which involves taking the medication and following the instructions in terms of the schedule and the food that accompanies the intake [3]. Previous studies have reported adherence rates ranging from 26–89% [11–14]. The variability in reported adherence rates depends on the operational definition of adherence and the instrument used for its measurement [15]. The pharmacological adherence is overestimated when it is calculated based on the ratio of pills forgotten and prescribed in the last days. A more precise evaluation requires the inclusion of aspects such as the follow-up of the schedule and special instructions or the last missed dose [16]. It is worth mentioning that several patterns of pharmacological nonadherence have been identified: difficulties to initiate treatment, temporary suspension (whose duration is variable), or definitive abandonment, which represents a long-term pattern [17]. Nonadherence may be due to error or forgetfulness of the medication intake, as well as the conscious decision to abandon the treatment or not follow it properly [10].

(2) the patient is adherent at the pharmacological level, but not at the nonpharmacological level (scenario where the patient takes the medication, but does not perform the other types of care); (3) the patient is adherent at the nonpharmacological level, but not at the pharmacological level (scenario where the patient performs healthcare practices, but does not take the medication according to the indications); and (4) the patient is not adherent in both dimen-

The Process of Adherence to Treatment in People Living with HIV

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

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It should be mentioned that the identification of a patient as adherent will depend on the way in which the health personnel evaluate the taking of the medication and the recommendations of food and schedule (pharmacological adherence), as well as the evaluation of the degree of accomplishment of the practices in different areas of care (nonpharmacological adherence). Adherence can be considered in terms of degrees of a continuum; however, it is also necessary to establish what is the sufficient level of pharmacological and nonpharmacological adherence. This implies the need for a continuous dialog between the patient and the health personnel, in order to determine the levels of pharmacological and nonpharmacological adherence required, collaborate in the monitoring of the types of adherence, and receive feedback on the

Before reaching an optimal level of adherence, patients can alternate between periods of adherence and nonadherence until achieving an adequate and stable adherence. Traditionally it has been considered that patients are rational subjects who make a balance between the benefits and the costs of treatment to decide if they will remain adherent. However, it is necessary to consider the affective dimension, since patients not only accept treatment, they can also experience ambivalence or rejection toward treatment. It is necessary to remember that illness generates discomfort in function of the rupture it causes in the life of patients, since it affects their biography, identity, daily world, and social relations. Patients not only have the task of taking care of their health and adhering to treatment, simultaneously they embark on the tasks of giving meaning to life with the HIV infection and the reconstruction of their social

Adherence can be seen as a dialectical process where facilitators and barriers coexist during treatment. In the next section, the main facilitators and barriers to adherence reported in the literature, whether at the individual, interpersonal, or contextual levels will be

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

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

• Factors related to personal attributes. They include the patient's clinical status, educational

sions (the worst-case scenario).

actions performed by both actors to maintain adherence.

world to incorporate illness in everyday life [18].

the perspective of the researchers [19]:

level, income, access to housing, and stability of the home.

reviewed.

**with HIV**

The patient not only decides whether or not to initiate HAART but also decides whether to adopt a new lifestyle. The second dimension is associated with nonpharmacological adherence, which encompasses a set of practices that promote the patient's health care. It includes practices in the areas of diet, physical activity, rest, sexual health, mental health, attendance at medical appointments and attendance to laboratory studies, and avoidance of alcohol, tobacco, or other substances. Medication intake needs to be complemented by a series of healthy practices to promote the care of the patient and the improvement of their quality of life.

Adherence can be conceived as a process that develops over time. This process is affected by the socioeconomic position of the patient in a certain context, the dominant cultural values, and his personal experience with illness. At any point of time, the patient may be adherent or nonadherent. To be adherent, the patient needs to follow both pharmacological and nonpharmacological treatment. However, there is a risk that the patient develops patterns of nonadherence (pharmacological or nonpharmacological), which occur in the short term (at a point in time) or in the medium and long terms (at multiple time points) (**Figure 1**).

Four possible scenarios can be contemplated in a single moment of the treatment: (1) The patient is adherent at the pharmacological and nonpharmacological level (ideal scenario);

**Figure 1.** Adherence and nonadherence to treatment at a time point.

(2) the patient is adherent at the pharmacological level, but not at the nonpharmacological level (scenario where the patient takes the medication, but does not perform the other types of care); (3) the patient is adherent at the nonpharmacological level, but not at the pharmacological level (scenario where the patient performs healthcare practices, but does not take the medication according to the indications); and (4) the patient is not adherent in both dimensions (the worst-case scenario).

26–89% [11–14]. The variability in reported adherence rates depends on the operational definition of adherence and the instrument used for its measurement [15]. The pharmacological adherence is overestimated when it is calculated based on the ratio of pills forgotten and prescribed in the last days. A more precise evaluation requires the inclusion of aspects such as the follow-up of the schedule and special instructions or the last missed dose [16]. It is worth mentioning that several patterns of pharmacological nonadherence have been identified: difficulties to initiate treatment, temporary suspension (whose duration is variable), or definitive abandonment, which represents a long-term pattern [17]. Nonadherence may be due to error or forgetfulness of the medication intake, as well as the conscious decision to abandon the

The patient not only decides whether or not to initiate HAART but also decides whether to adopt a new lifestyle. The second dimension is associated with nonpharmacological adherence, which encompasses a set of practices that promote the patient's health care. It includes practices in the areas of diet, physical activity, rest, sexual health, mental health, attendance at medical appointments and attendance to laboratory studies, and avoidance of alcohol, tobacco, or other substances. Medication intake needs to be complemented by a series of healthy prac-

Adherence can be conceived as a process that develops over time. This process is affected by the socioeconomic position of the patient in a certain context, the dominant cultural values, and his personal experience with illness. At any point of time, the patient may be adherent or nonadherent. To be adherent, the patient needs to follow both pharmacological and nonpharmacological treatment. However, there is a risk that the patient develops patterns of nonadherence (pharmacological or nonpharmacological), which occur in the short term (at a point

Four possible scenarios can be contemplated in a single moment of the treatment: (1) The patient is adherent at the pharmacological and nonpharmacological level (ideal scenario);

tices to promote the care of the patient and the improvement of their quality of life.

in time) or in the medium and long terms (at multiple time points) (**Figure 1**).

**Figure 1.** Adherence and nonadherence to treatment at a time point.

treatment or not follow it properly [10].

106 Advances in HIV and AIDS Control

It should be mentioned that the identification of a patient as adherent will depend on the way in which the health personnel evaluate the taking of the medication and the recommendations of food and schedule (pharmacological adherence), as well as the evaluation of the degree of accomplishment of the practices in different areas of care (nonpharmacological adherence). Adherence can be considered in terms of degrees of a continuum; however, it is also necessary to establish what is the sufficient level of pharmacological and nonpharmacological adherence. This implies the need for a continuous dialog between the patient and the health personnel, in order to determine the levels of pharmacological and nonpharmacological adherence required, collaborate in the monitoring of the types of adherence, and receive feedback on the actions performed by both actors to maintain adherence.

Before reaching an optimal level of adherence, patients can alternate between periods of adherence and nonadherence until achieving an adequate and stable adherence. Traditionally it has been considered that patients are rational subjects who make a balance between the benefits and the costs of treatment to decide if they will remain adherent. However, it is necessary to consider the affective dimension, since patients not only accept treatment, they can also experience ambivalence or rejection toward treatment. It is necessary to remember that illness generates discomfort in function of the rupture it causes in the life of patients, since it affects their biography, identity, daily world, and social relations. Patients not only have the task of taking care of their health and adhering to treatment, simultaneously they embark on the tasks of giving meaning to life with the HIV infection and the reconstruction of their social world to incorporate illness in everyday life [18].

Adherence can be seen as a dialectical process where facilitators and barriers coexist during treatment. In the next section, the main facilitators and barriers to adherence reported in the literature, whether at the individual, interpersonal, or contextual levels will be reviewed.
