Journal of General Internal Medicine

, Volume 18, Issue 2, pp 104–111 | Cite as

Association of social stress, illicit drug use, and health beliefs with nonadherence to antiretroviral therapy

Original Articles


OBJECTIVE: To assess the roles of socioeconomic status, social stability, social stress, health beliefs, and illicit drug use with nonadherence to antiretroviral therapy.

DESIGN: Cross-sectional study.

SETTING: Urbcan hospital clinic.

PARTICIPANTS: One hundred ninety-six consecutive HIV-infected patients taking at least 1 antiretroviral medication, awaiting a visit with their primary care provider.

METHODS: Patients were interviewed while waiting for a clinic appointment and were asked to fill out a 4-part survey with questions regarding antiretroviral adherence, illicit drug use, health beliefs, and social situation. Adherence was defined as the percentage of doses taken, i.e., the number of doses taken divided by the number of doses prescribed over a 2-week interval. Univeriate and multivariate logistic regressions were performed to identify factors associated with nonadherence in different patient subgroups.

MAIN RESULTS: Nonadherence to antiretroviral therapy was associated with active illicit drug use (adjusted odds ratio [AOR], 2.31; 95% confidence interval [95% CI], 1.17 to 4.58), eating fewer than 2 meals per day (AOR, 3.31; 95% CI, 1.11 to 9.92), and feeling as though pressures outside of the clinic affected patient’s ability to take antiretroviral medications as prescribed (AOR, 2.22; 95% CI, 0.99 to 4.97). In patients with a history of injection drug use, nonadherence to antiretroviral therapy was independently associated with eating fewer than 2 meals per day (AOR, 17.54; 95% CI, 1.92 to 160.4) and active illicit drug use (AOR, 4.18; 95% CI, 1.68 to 10.75). In patients without any injection drug use, nonadherence was only associated with feeling as though pressures outside of clinic affected patient’s ability to take antiretroviral medications as prescribed (AOR, 3.55; 95% CI, 1.07 to 11.76). Male-to-male sexual contact was associated with lower nonadherence in patients with an HIV risk factor other than injection drug use (AOR, 0.35; 95% CI, 0.13 to 0.95). A history of drug use but no illicit drug use within 6 months of the interview was not associated with an increased rate of nonadherence.

CONCLUSIONS: Although our sample size was limited and variables that are not significant in subgroup analysis may still be associated with adherence, our results suggest that correlates of nonadherence are HIV risk factor specific. Strategies to increase antiretroviral adherence in HIV-infected patients should include social support interventions targeted at different risk factors for different patient groups.

Key words

adherence antiretroviral therapy drug use HIV socioeconomic status 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Hogg RS, Heath KV, Yip B, et al. Improved survival among HIV-infected individuals following initiation of antiretroviral therapy. JAMA. 1998;279:450–4.PubMedCrossRefGoogle Scholar
  2. 2.
    Palella FJ Jr, Delaney KM, Moorman AC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N Engl J Med. 1998;338:853–60.PubMedCrossRefGoogle Scholar
  3. 3.
    Hecht FM, Grant RM, Petropoulos CJ, et al. Sexual transmission of an HIV-1 variant resistant to multiple reverse-transcriptase and protease inhibitors. N Engl J Med. 1998;339:307–11.PubMedCrossRefGoogle Scholar
  4. 4.
    Mostashari F, Riley E, Selwyn PA, Altice FL. Acceptance and adherence with antiretroviral therapy among HIV-infected women in a correctional facility. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18:341–8.PubMedGoogle Scholar
  5. 5.
    Samet JH, Libman H, Steger KA, et al. Compliance with zidovudine therapy in patients infected with human immunodeficiency virus, type 1: a cross-sectional study in a municipal hospital clinic. Am J Med. 1992;92:495–502.PubMedCrossRefGoogle Scholar
  6. 6.
    Singh N, Squier C, Sivek C, Wagener M, Nguyen MH, Yu VL. Determinants of compliance with antiretroviral therapy in patients with human immunodeficiency virus: prospective assessment with implications for enhancing compliance. AIDS Care. 1996;8:261–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAulif TL. Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychol. 2000;19:124–33.PubMedCrossRefGoogle Scholar
  8. 8.
    Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med. 1999;14:267–73.PubMedCrossRefGoogle Scholar
  9. 9.
    Ohmit S, Schuman P, Schoenbaum E, et al. Adherence to antiretroviral therapy (ART) among women in the HIV Epidemiology Research Study (HERS) and Women’s Inter-Agency HIV Study (WIHS). In: Abstract 3247, 12th World AIDS Conference, Geneva, June 28–July 3, 1998.Google Scholar
  10. 10.
    Eldred LJ, Wu AW, Chaisson RE, Moore RD. Adherence to antiretroviral and pneumocystis prophylaxis in HIV disease. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18:117–25.PubMedGoogle Scholar
  11. 11.
    Vlahov D, Anthony JC, Munoz A, et al. The ALIVE study, a longitudinal study of HIV-1 infection in intravenous drug users: description of methods and characteristics of participants. NIDA Res Monogr. 1991;109:75–100.PubMedGoogle Scholar
  12. 12.
    Chesney MA, Ickovics JR, Chambers DB, et al. Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: the AACTG adherence instruments. Patient Care Committee & Adherence Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group (AACTG). AIDS Care. 2000;12:255–66.PubMedCrossRefGoogle Scholar
  13. 13.
    Fowler FJ. Survey Research Methods. Bevery Hills, Calif: Sage; 1984Google Scholar
  14. 14.
    Bangsberg DR, Perry S, Charlebois ED, et al. Non-adherence to highly active antiretroviral therapy predicts progression to AIDS. AIDS. 2001;15:1181–3.PubMedCrossRefGoogle Scholar
  15. 15.
    Rodriguez-Rosado R, Jimenez-Nacher I, Soriano V, Anton P, Gonzalez-Lahoz J. Virological failure and adherence to antiretroviral therapy in HIV-infected patients. AIDS. 1998;12:1112–3.PubMedCrossRefGoogle Scholar
  16. 16.
    Lopez-Suarez A, Fernandez-Gutierrez del Alamo C, Perez-Guzman E, Giron-Gonzalez. Adherence to the antiretroviral treatment in asymptomatic HIV-infected patients. AIDS. 1998;12:685–6.PubMedGoogle Scholar
  17. 17.
    Paterson DL, Swindells S, Mohr J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med. 2000;133:21–30.PubMedGoogle Scholar
  18. 18.
    Broers B, Morabia A, Hirschel B. A cohort study of drug users’ compliance with zidovudine treatment. Arch Intern Med. 1994;154:1121–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Miller GE, Cole SW. Social relationships and the progression of human immunodeficiency virus infection: a review of evidence and possible underlying mechanisms. Ann Behav Med. 1998;20:181–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Gordillo V, del Amo J, Soriano V, Gonzalez-Lahoz J. Sociodemographic and psychological variables influencing adherence to antiretroviral therapy. AIDS. 1999;13:1763–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Martinez J, Bell D, Camacho R, et al. Adherence to antiviral drug regimens in HIV-infected adolescent patients engaged in care in a comprehensive adolescent and young adult clinic. J Natl Med Assoc. 2000;92:55–61.PubMedGoogle Scholar
  22. 22.
    Mehta S, Moore RD, Graham NM. Potential factors affecting adherence with HIV therapy. AIDS. 1997;11:1665–70.PubMedCrossRefGoogle Scholar
  23. 23.
    Kissinger P, Cohen O, Brandon W, Rice J, Morse A, Clark R. Compliance with public sector HIV medical care. J Natl Med Assoc. 1995;87:19–24.PubMedGoogle Scholar
  24. 24.
    Singh N, Berman SM, Swindells S, et al. Adherence of human immunodeficiency virus-infected patients to antiretroviral therapy. Clin Infect Dis. 1999;29:824–30.PubMedGoogle Scholar
  25. 25.
    Stone VE, Hogan JW, Schuman P, et al. Antiretroviral regimen complexity, self-reported adherence, and HIV patients’ understanding of their regimens: survey of women in the HER study. J Acquir Immune Defic Syndr. 2001;28:124–31.PubMedCrossRefGoogle Scholar
  26. 26.
    Arnsten JH, Demas PA, Farzadegan H, et al. Antiretroviral therapy adherence and viral suppression in HIV-infected drug users: comparison of self-report and electronic monitoring. Clin Infect Dis. 2001;33:1417–23.PubMedCrossRefGoogle Scholar
  27. 27.
    Bangsberg D, Tulsky JP, Hecht FM, Moss AR. Protease inhibitors in the homeless. JAMA. 1997;278:63–5.PubMedCrossRefGoogle Scholar
  28. 28.
    Bamberger JD, Unick J, Klein P, Fraser M, Chesney M, Katz MH. Helping the urban poor stay with antiretroviral HIV drug therapy. Am J Public Health. 2000;90:699–701.PubMedCrossRefGoogle Scholar
  29. 29.
    Altice FL, Khoshnood K, Eicher A, Pinell V. Transitional case management for HIV+ prisoners in Connecticut (abstract). Presented at the 124th Annual Meeting of the American Public Health Association, New York, NY, November 1996.Google Scholar
  30. 30.
    Altice FL, Mostashari F, Thompson AS, Friedland GH. Perceptions, acceptance and adherence to antiretrovirals among prisoners. Presented at the Fourth Conference on Retroviruses and Opportunistic Infections, Washington DC, January 22–26, 1997.Google Scholar
  31. 31.
    Altice FL, Friedland GH. The era of adherence to HIV therapy. Ann Intern Med. 1998;129:503–5.PubMedGoogle Scholar
  32. 32.
    Bangsberg DR, Hecht FM, Clague H, et al. Provider assessment of adherence to HIV antiretroviral therapy. J Acquire Immun Defic Syndr. 2001;26:435–42.Google Scholar
  33. 33.
    Haynes RB, McKibbon KA, Kanani R. Systematic review of randomized trials of interventions to assist patients to follow prescription medications. Lancet. 1998;348:383–6.Google Scholar
  34. 34.
    Wall TL, Sorensen JL, Batki SL, Delucchi KL, London JA, Chesney MA. Adherence to zidovudine (AZT) among HIV-infected methadone patients: a pilot study of supervised therapy and dispensing compared to usual care. Drug Alcohol Depend. 1995;37:261–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Liu H, Golin CE, Miller LG, et al. A comparison study of multiple measures of adherence to HIV protease inhibitors. Ann Intern Med. 2001;134:968–77.PubMedGoogle Scholar
  36. 36.
    Montaner JS, Reiss P, Cooper D, et al. A randomized, double-blind trial comparing combinations of nevirapine, didanosine, and zidovudine for HIV-infected patients: the INCAS Trial. Italy, The Netherlands, Canada and Australia Study. JAMA. 1998;279:930–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Haubrich RH, Little SJ, Currier JS, et al. The value of patient-reported adherence to antiretroviral therapy in predicting virologic and immunologic response. California Collaborative Treatment Group. AIDS. 1999;13:1099–107.PubMedCrossRefGoogle Scholar
  38. 38.
    d’Arminio Monforte A, Testa L, Adorni F, et al. Clinical outcome and predictive factors of failure of highly active antiretroviral therapy in antiretroviral-experienced patients in advanced stages of HIV-1 infection. AIDS. 1998;12:1631–7.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2003

Authors and Affiliations

  • Kelly A. Gebo
    • 1
  • Jeanne Keruly
  • Richard D. Moore
  1. 1.Johns Hopkins University School of MedicineBaltimore, MD

Personalised recommendations