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Hosseini Z, Ebadi A, Aghamolaei T, Nedjat S. A model for explaining adherence to antiretroviral therapy in patients with HIV/AIDS: A grounded theory study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e5735-e5744. [PMID: 36102307 DOI: 10.1111/hsc.14004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 08/13/2022] [Accepted: 08/20/2022] [Indexed: 06/15/2023]
Abstract
Maintaining a high level of adherence to antiretroviral therapy is a challenge among HIV/AIDS patients. The study aimed to explore the process of adherence to treatment with a grounded theory approach to help physicians and planners develop strategies to increase adherence to treatment. We conducted in-depth interviews and a focus-group discussion. The data were collected from 2016 to 2018. The participants were 39 HIV/AIDS patients treated with antiretroviral, their relatives (three people) and two treatment staff. The study was conducted at the Behavioural Counselling Center of Imam Khomeini Hospital, located in Tehran, the capital of Iran. The data were analysed at the stages of "analysis for concepts," "analysis for context," "bringing process into the analysis" and "integrating." We obtained a conceptual model to explain the relationship between the categories. "Motivation" was identified as the core variable and the "Becoming resilient" explained the adherence process. Several factors including the interfering factors, contextual factors and resilience factors were identified. The interfering and contextual factors, in the absence of the resilience factors, lead to decreased motivation and increased poor adherence to treatment. The role of motivation in long-term adherence should be emphasised. We think strategies such as helping individuals with HIV/AIDS to form support networks, empowering and encouraging them to seek spiritual help will motivate them to maintain a long-term use of antiretroviral medications and, hence, become more resilient.
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Affiliation(s)
- Zahra Hosseini
- Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Abbas Ebadi
- School of Nursing and Midwifery, Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Teamur Aghamolaei
- Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Saharnaz Nedjat
- Department of Epidemiology and Biostatistics, School of Public Health, Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Pollack TM, Duong HT, Nhat Vinh DT, Phuong DT, Thuy DH, Nhung VTT, Uyen NK, Linh VT, Van Truong N, Le Ai KA, Ninh NT, Nguyen A, Canh HD, Cosimi LA. A pretest-posttest design to assess the effectiveness of an intervention to reduce HIV-related stigma and discrimination in healthcare settings in Vietnam. J Int AIDS Soc 2022; 25 Suppl 1:e25932. [PMID: 35818864 PMCID: PMC9274370 DOI: 10.1002/jia2.25932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 05/03/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Stigma and discrimination are important barriers to HIV epidemic control. We implemented a multi‐pronged facility‐level intervention to reduce stigma and discrimination at health facilities across three high‐burden provinces. Key components of the intervention included measurement of stigma, data review and use, participatory training of healthcare workers (HCWs), and engagement of people living with HIV and key populations in all stigma reduction activities. Methods From July 2018 to July 2019, we assessed HIV‐related stigma and discrimination among patients and HCWs at 10 facilities at baseline and 9 months following an intervention. A repeated measures design was used to assess the change in stigma and discrimination among HCWs and a repeated cross‐sectional design assessed the change in stigma and discrimination experienced by PLHIV. HCWs at target facilities were invited at random and PLHIV were recruited when presenting for care during the two assessment periods. McNemar's test was used to compare paired proportions among HCWs, and chi‐square test was used to compare proportions among PLHIV. Mixed models were used to compare outcomes before and after the intervention. Results Semi‐structured interviews were conducted with 649 and 652 PLHIV prior to and following the intervention, respectively. At baseline, over the previous 12 months, 21% reported experiencing discrimination, 16% reported self‐stigma, 14% reported HIV disclosure without consent and 7% had received discriminatory reproductive health advice. Nine months after the intervention, there was a decrease in reported stigma and discrimination across all domains to 15%, 11%, 7% and 3.5%, respectively (all p‐values <0.05). Among HCWs, 672 completed the pre‐ and post‐intervention assessment. At baseline, 81% reported fear of HIV infection, 69% reported using unnecessary precautions when caring for PLHIV, 44% reported having observed other staff discriminate against PLHIV, 54% reported negative attitudes towards PLHIV and 41% felt uncomfortable working with colleagues living with HIV. The proportions decreased after the intervention to 52%, 34%, 32%, 35% and 24%, respectively (all p‐values <0.05). Conclusions A multi‐pronged facility‐level intervention was successful at reducing healthcare‐associated HIV‐related stigma in Vietnam. The findings support the scale‐up of this intervention in Vietnam and highlight key components potentially applicable in other settings.
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Affiliation(s)
- Todd M Pollack
- Partnership for Health Advancement in Vietnam, Hanoi, Vietnam.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Baylor College of Medicine, Houston, Texas, USA
| | - Hao Thi Duong
- Partnership for Health Advancement in Vietnam, Hanoi, Vietnam.,Baylor College of Medicine, Houston, Texas, USA
| | | | - Do Thi Phuong
- Partnership for Health Advancement in Vietnam, Hanoi, Vietnam
| | - Do Huu Thuy
- Vietnam Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
| | | | | | - Vuong The Linh
- Binh Duong Center for Disease Control, Binh Duong, Vietnam
| | | | - Kim Anh Le Ai
- Thai Nguyen Center for Disease Control, Thai Nguyen, Vietnam
| | | | - Asia Nguyen
- Division of Global HIV and TB, Center for Global Health, United States Centers for Disease Control and Prevention Vietnam, Hanoi, Vietnam
| | - Hoang Dinh Canh
- Vietnam Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
| | - Lisa A Cosimi
- Partnership for Health Advancement in Vietnam, Hanoi, Vietnam.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Cunha APD, Cruz MMD, Pedroso M. Analysis of the trend of mortality from HIV/AIDS according to sociodemographic characteristics in Brazil, 2000 to 2018. CIENCIA & SAUDE COLETIVA 2022; 27:895-908. [PMID: 35293467 DOI: 10.1590/1413-81232022273.00432021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/01/2021] [Indexed: 11/22/2022] Open
Abstract
This investigation analyzed the trend of HIV/AIDS mortality by sociodemographic characteristics in the Brazilian states from 2000 to 2018. This is an ecological study of time-series of standardized rates of mortality from AIDS overall, by gender, age group, marital status, and ethnicity/skin color, employing the Prais-Winsten generalized linear model. The results showed that the states with the highest rates were Rio Grande do Sul, Rio de Janeiro, São Paulo, and Santa Catarina. The trend was increasing in the North and Northeast. Men had higher rates than women and the general population. The most advanced age groups showed a growing trend. The analysis by marital status showed higher and growing rates among the unmarried. Blacks had higher rates, except for Paraná, with a mainly increasing trend. Mortality due to HIV/AIDS had different trends by sociodemographic characteristics, with a need for preventive and care actions for men, adults, older adults, unmarried, and black people due to the change in the mortality profile.
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Affiliation(s)
- Ana Paula da Cunha
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz. R. Leopoldo Bulhões 1.480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil.
| | - Marly Marques da Cruz
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz. R. Leopoldo Bulhões 1.480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil.
| | - Marcel Pedroso
- Instituto de Comunicação e Informação Científica e Tecnológica, Fundação Oswaldo Cruz. Rio de Janeiro RJ Brasil
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Rzeszutek M, Gruszczyńska E, Pięta M, Malinowska P. HIV/AIDS stigma and psychological well-being after 40 years of HIV/AIDS: a systematic review and meta-analysis. Eur J Psychotraumatol 2021; 12:1990527. [PMID: 34868481 PMCID: PMC8635597 DOI: 10.1080/20008198.2021.1990527] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 01/01/2023] Open
Abstract
Background In June 2021, 40 years have passed since the first cases of HIV infection were detected. Nonetheless, people living with HIV (PLWH) still suffer from intense HIV-related distress and trauma, which is nowadays mostly linked to the still-existing stigmatization of PLWH. Objectives The aim of this systematic review and meta-analysis was to examine the association between HIV/AIDS stigma and psychological well-being among PLWH. We also explored whether this association varies as a function of sociodemographic and clinical characteristics as well as study publication year and stigma measurement. Method A structured literature search was performed on Web of Science, Scopus, PsyARTICLES, MedLine, ProQuest, and Google Scholar databases. The inclusion criteria were quantitative, peer-reviewed articles published in English between 1996 and 2020. Results After selection, 64 articles were accepted for further analysis (N = 25,294 participants). The random-effects pooled estimate revealed an overall negative and medium-strength association between stigma and well-being (r = -.31, 95% CI [-.35; -.26]). The participants' age modified this effect with a stronger association for older PLWH. Other sociodemographic and clinical variables as well as publication year and stigma measurement did not explain the variation in association between stigma and well-being across studies. Conclusions The present meta-analysis and systematic review not only showed an expected negative relationship between stigma and well-being but also revealed a substantial heterogeneity between studies that suggests a strong role of context of a given study. This finding calls for more advanced theoretical and analytical models to identify protective and vulnerability factors to effectively address them in clinical practice and interventions.
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Affiliation(s)
| | - Ewa Gruszczyńska
- Faculty of Psychology, SWPS University of Social Sciences and Humanities, Warsaw, Poland
| | | | - Paula Malinowska
- Faculty of Psychology, SWPS University of Social Sciences and Humanities, Warsaw, Poland
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Ahmed A, Saqlain M, Bashir N, Dujaili J, Hashmi F, Mazhar F, Khan A, Jabeen M, Blebil A, Awaisu A. Health-related quality of life and its predictors among adults living with HIV/AIDS and receiving antiretroviral therapy in Pakistan. Qual Life Res 2021; 30:1653-1664. [PMID: 33582967 PMCID: PMC8178128 DOI: 10.1007/s11136-021-02771-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Health-related quality of life (HRQoL) is considered to be the fourth 90 of UNAIDS 90-90-90 target to monitor the effects of combination antiretroviral therapy (ART). ART has significantly increased the life expectancy of people living with HIV/AIDS (PLWHA). However, the impact of chronic infection on HRQoL remains unclear, while factors influencing the HRQoL may vary from one country to another. The current study aimed to assess HRQoL and its associated factors among PLWHA receiving ART in Pakistan. METHODS A cross-sectional descriptive study was conducted among PLWHA attending an ART centre of a tertiary care hospital in Islamabad, Pakistan. HRQoL was assessed using a validated Urdu version of EuroQol 5 dimensions 3 level (EQ-5D-3L) and its Visual Analogue Scale (EQ-VAS). RESULTS Of the 602 patients included in the analyses, 59.5% (n = 358) reported no impairment in self-care, while 63.1% (n = 380) were extremely anxious/depressed. The overall mean EQ-5D utility score and visual analogue scale (EQ-VAS) score were 0.388 (SD: 0.41) and 66.20 (SD: 17.22), respectively. Multivariate linear regression analysis revealed that the factors significantly associated with HRQoL were: female gender; age > 50 years; having primary and secondary education; > 1 year since HIV diagnosis; HIV serostatus AIDS-converted; higher CD 4 T lymphocytes count; detectable viral load; and increased time to ART. CONCLUSIONS The current findings have shown that PLWHA in Pakistan adherent to ART had a good overall HRQoL, though with significantly higher depression. Some of the factors identified are amenable to institution-based interventions while mitigating depression to enhance the HRQoL of PLWHA in Pakistan. The HRQoL determined in this study could be useful for future economic evaluation studies for ART and in designing future interventions.
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Affiliation(s)
- Ali Ahmed
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500 Subang Jaya, Selangor Malaysia
| | - Muhammad Saqlain
- Department of Pharmacy, Quaid I Azam University Islamabad, Islamabad, Pakistan
| | - Naila Bashir
- HIV Treatment Center, Pims, National AIDs Control Programme, Islamabad, Pakistan
| | - Juman Dujaili
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500 Subang Jaya, Selangor Malaysia
| | - Furqan Hashmi
- University College of Pharmacy, University of the Punjab, Allama Iqbal Campus, Lahore, 54000 Pakistan
| | - Faizan Mazhar
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, “Luigi Sacco” University Hospital, Università Di Milano, 20157 Milan, Italy
| | - Amjad Khan
- Department of Pharmacy, Quaid-I-Azam university, Islamabad, Pakistan
| | | | - Ali Blebil
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, 47500 Subang Jaya, Selangor Malaysia
| | - Ahmed Awaisu
- Department of Clinical Pharmacy & Practice, College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
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Bui TM, Hoang MT, Ngo TV, Do CD, Nghiem SH, Byrnes J, Phung DT, Nguyen THT, Vu GT, Do HT, Latkin CA, Ho RC, Ho CS. Smartphone Use and Willingness to Pay for HIV Treatment-Assisted Smartphone Applications among HIV-Positive Patients in Urban Clinics of Vietnam. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041467. [PMID: 33557412 PMCID: PMC7915809 DOI: 10.3390/ijerph18041467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 11/28/2022]
Abstract
This study aimed to examine the effectiveness of Human Immunodeficiency Virus (HIV)-assisted smartphone applications in the treatment of HIV/AIDS patients in Vietnam. A cross-sectional study was performed in two urban outpatient clinics in Hanoi from May to December 2019. A simple random sampling method and a structured questionnaire were used to recruit 495 eligible participants and to collect data. Multivariable modified Poisson regression and multivariable linear regression models were employed to investigate the factors associated with the willingness to pay (WTP) and amount of money patients were willing to pay. Approximately 82.8% of respondents were willing to pay for the hypothetical applications, with the mean amount the participants were willing to pay of Vietnam Dong (VND) 72,100/month. Marital status (separate/divorced/widow: Odds ratio (OR) = 1.28, 95% confidence interval (CI) = (1.09; 1.50) and having spouse/partner: OR = 1.18, 95% CI = (1.03; 1.36)) and using health services (OR = 1.03, 95% CI = (1.01; 1.04)) were positively associated with nominating they would be WTP for the app, whereas the duration of antiretroviral treatment (ART) (OR = 0.98, 95% CI = (0.96; 0.99)) had a negative association. The frequency of using health services (β = 0.04, 95% CI = (−0.07; −0.01)) was negatively associated with the amount of WTP. High levels of WTP revealed the feasibility of implementing smartphone-based apps for HIV treatment. This study implied the necessity to consider a co-payment system to reach populations who were in need but where such applications may be unaffordable in lieu of other treatment-associated expenses. Developers also need to pay attention to privacy features to attract single people living with HIV/AIDS and additional measures to initiate people with a long duration on ART into using the applications.
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Affiliation(s)
- Thu Minh Bui
- Bach Mai Medical College, Bach Mai Hospital, Hanoi 100000, Vietnam;
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi 100000, Vietnam;
| | - Men Thi Hoang
- Institute for Global Health Innovations, Duy Tan University, Da Nang 550000, Vietnam;
- Faculty of Medicine, Duy Tan University, Da Nang 550000, Vietnam
- Correspondence: ; Tel.: +84-902-850-236
| | - Toan Van Ngo
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi 100000, Vietnam;
| | - Cuong Duy Do
- National Hospital of Tropical Diseases, Bach Mai Hospital, Hanoi 100000, Vietnam;
| | - Son Hong Nghiem
- Centre for Applied Health Economics (CAHE), Griffith University, Brisbane, QLD 4222, Australia; (S.H.N.); (J.B.)
| | - Joshua Byrnes
- Centre for Applied Health Economics (CAHE), Griffith University, Brisbane, QLD 4222, Australia; (S.H.N.); (J.B.)
| | - Dung Tri Phung
- School of Medicine, Griffith University, Gold Coast Campus, Parklands Drive, Southport, QLD 4222, Australia;
| | - Trang Huyen Thi Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang 550000, Vietnam;
- Faculty of Medicine, Duy Tan University, Da Nang 550000, Vietnam
| | - Giang Thu Vu
- Center of Excellence in Evidence-Based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City 700000, Vietnam;
| | - Hoa Thi Do
- Institute of Health Economics and Technology, Hanoi 100000, Vietnam;
| | - Carl A. Latkin
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA;
| | - Roger C.M. Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119074, Singapore; (R.C.M.H.); (C.S.H.H.)
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore 119074, Singapore
| | - Cyrus S.H. Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119074, Singapore; (R.C.M.H.); (C.S.H.H.)
- Department of Psychological Medicine, National University Health System, Singapore 119228, Singapore
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Koseoglu Ornek O, Tabak F, Mete B. Stigma in Hospital: an examination of beliefs and attitudes towards HIV/AIDS patients, Istanbul. AIDS Care 2020; 32:1045-1051. [PMID: 32449413 DOI: 10.1080/09540121.2020.1769833] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
HIV/AIDS-related stigma remains a crucial public health problem in the world. Unfortunately, health provider staffs such as nurses and physicians are the major source of stigmatization and discrimination against peoples living with HIV (PLHIVs) including in Turkey. The aim of this study was to assess HIV-related stigma towards to PLHIV by nurses and physicians and to examine related factors. Descriptive Assessment Form and the HIV-Related Stigma Scale used for data collection. The study consisted of 405 health workers including 251 nurses and 154 physicians. Over 86% of physicians and 69.3% of nurses had no specific education about HIV. More than 11% of the nurses and 8.4% of the physicians expressed that HIV can be transmitted with handshaking or breathing in a shared environment. Fear-driven stigma was significantly different by age, education, occupation, and work experience. Over 14% of the discrimination (Adjusted R 2 = .14 F(15-389) = 4.46 P = .000), and 10% of the disclosure were explained by the variables (Adjusted R 2 = .10 F(15-389) = 4.29 P = .000). The discrimination dimension had a strong positive relationship with the knowledge of HIV transmission modes. In our view, if physicians and nurses receive adequate and comprehensive training on HIV including stigma, the formations of stigma may be prevented and may not develop.
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Affiliation(s)
- Ozlem Koseoglu Ornek
- Occupational and Environmental Epidemiology & NetTeaching Unit, Institute and Clinic for Occupational, Social and Environmental Medicine; University Hospital, LMU Munich, Munich, Germany.,Department of Nursing, Faculty of Health Sciences, Istanbul Bilgi University, Istanbul, Turkey
| | - Fehmi Tabak
- Faculty of Medicine, Head of Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Birgul Mete
- Faculty of Medicine, Head of Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
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Lee SA, Kim EY, Chang SO. A life where concealment and exposure coexist-The antiretroviral therapy adherence of people living with HIV infection: A phenomenological study. J Adv Nurs 2020; 76:1027-1036. [PMID: 32003040 DOI: 10.1111/jan.14309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/08/2020] [Accepted: 01/21/2020] [Indexed: 11/29/2022]
Abstract
AIM The aim of this study is to identify the nature and structure of the real world experiences of people living with HIV infection and adhering to antiretroviral therapy (ART). DESIGN Giorgi's phenomenological method was applied. METHODS Data collection was conducted from 1 November 2016-1 September 2017. A total of six participants participated in the study. The Consolidated Criteria for Reporting Qualitative Research (COREQ) was used to report this study. RESULTS The findings show that the structure of the experience of people living with HIV and adhering to ART is composed of six essential common constituents: (a) ART adherence has become a prerequisite for a normal life; (b) Endless adjustments responding to a sensitive body; (c) Dosing Time becomes the framework of the day; (d) Dosing time needing to coincide with the availability of confidential dosing space; (e) Classification of Relationships-those who know of my taking antiretroviral drugs and those who do not; and (f) Recognition of the multiple relationships affecting ART. CONCLUSION Adhering to ART is experienced by people infected with HIV not only as a process they want to hide, but also a critical lifeline that stabilizes their lives. That is, their day-to-day living is split into a double life reflecting their coexisting need for concealment and exposure. IMPACT Although much existing literature focuses on the adherence to medication, this study reveals the meaning of ART in the context of viewing the patient as an independent subject. Contrary with what people living with HIV want, they are at risk of external exposure during the process of treatment. This study highlights the need for nurses to communicate with patients about the strategies they need to meet the challenges they face.
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Affiliation(s)
- Sun-A Lee
- National Medical Center, Seoul, Republic of Korea
| | - Eun Y Kim
- Red Cross College of Nursing, Chung-Ang University, Seoul, Republic of Korea
| | - Sung O Chang
- College of Nursing, Korea University, Seoul, Republic of Korea
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