Tment adherence by incorporatingPLOS ONE | DOI:10.1371/journal.pone.0125582 September 30,14 /Barriers and Facilitators for HIV Treatment Adherence in Puerto Ricansother types of questions or interviewing stakeholders or actors representing multiple systems (e.g. clinicians, administrators, etc.). Adherence facilitator categories were also subject of grounded analysis. As expected, social support was the most common cited facilitator for adherence (G = 18) by participants. Other studies have identified social support as a potential HAART adherence facilitator. For example, a cohort study conducted by Achieng et. al. (2012) looking for facilitators of retention in care and antiretroviral treatment adherence in Kenya found that among other factors, participation in support groups predicted better adherence, and time to treatment failure reduction [36]. One interesting finding about adherence facilitators was the emergence of concerns with health status (G = 10). These concerns were either imaginary (fear of health deterioration) or real (actual health deterioration). The fact that some participants waited until their health deteriorated to take their medication is like playing at the “Russian roulette”. It represents a very dangerous facilitator because the patient’s life is placed at risk, and it further complicates their care. Patients relying on this facilitator are probably using the psychological defense mechanism of denial, making contact with the reality of their diagnosis only when the physical signs of an opportunistic condition appear. The development of effective strategies to identify and tackle this dangerous facilitator is recommended. Questions about primary health care (PHC) interactions were added in this study in an effort to expand our understanding of PHC recommendation adherence among participants. Some participants identified patient level barriers, such as fear or shame about certain clinical procedures and substance abuse, as well as exo-system level barriers, such as transportation problems. However, we did not find enough evidence of saturation of barriers to PHC recommendations, as most participants stated they followed their primary health care recommendations. The identified barriers are common in the general populations as well [37?8]. One potential explanation is that some PHC services provided to the patients were incorporated in the purchase NVP-QAW039 clinic where recruitment took place, thus, facilitating access and further adherence of such recommendations.Strengths and LimitationsOne of the strengths of this study is the use of a social ecological model to provide a comprehensive view of the HAART non-adherence phenomenon. This approach has been recommended elsewhere [18] and we have received a broader response from participants by using a comprehensive interview guide. A ARRY-334543 price limitation of the study was having only one recruitment site, thus limiting the emergence of other system barriers jir.2010.0097 or facilitators attached to other site realities. Another limitation was the sample size. Although twelve is an acceptable number of participants for a descriptive study, it may not be enough to reach saturation of certain phenomena; such was the case of PHC recommendation barriers.ConclusionThe results of this study suggest the interconnection of HIV treatment adherence barriers at various system levels. Future studies on HIV treatment barriers should explore these interactions and investigate the possible synergistic effect on non-adherent.Tment adherence by incorporatingPLOS ONE | DOI:10.1371/journal.pone.0125582 September 30,14 /Barriers and Facilitators for HIV Treatment Adherence in Puerto Ricansother types of questions or interviewing stakeholders or actors representing multiple systems (e.g. clinicians, administrators, etc.). Adherence facilitator categories were also subject of grounded analysis. As expected, social support was the most common cited facilitator for adherence (G = 18) by participants. Other studies have identified social support as a potential HAART adherence facilitator. For example, a cohort study conducted by Achieng et. al. (2012) looking for facilitators of retention in care and antiretroviral treatment adherence in Kenya found that among other factors, participation in support groups predicted better adherence, and time to treatment failure reduction [36]. One interesting finding about adherence facilitators was the emergence of concerns with health status (G = 10). These concerns were either imaginary (fear of health deterioration) or real (actual health deterioration). The fact that some participants waited until their health deteriorated to take their medication is like playing at the “Russian roulette”. It represents a very dangerous facilitator because the patient’s life is placed at risk, and it further complicates their care. Patients relying on this facilitator are probably using the psychological defense mechanism of denial, making contact with the reality of their diagnosis only when the physical signs of an opportunistic condition appear. The development of effective strategies to identify and tackle this dangerous facilitator is recommended. Questions about primary health care (PHC) interactions were added in this study in an effort to expand our understanding of PHC recommendation adherence among participants. Some participants identified patient level barriers, such as fear or shame about certain clinical procedures and substance abuse, as well as exo-system level barriers, such as transportation problems. However, we did not find enough evidence of saturation of barriers to PHC recommendations, as most participants stated they followed their primary health care recommendations. The identified barriers are common in the general populations as well [37?8]. One potential explanation is that some PHC services provided to the patients were incorporated in the clinic where recruitment took place, thus, facilitating access and further adherence of such recommendations.Strengths and LimitationsOne of the strengths of this study is the use of a social ecological model to provide a comprehensive view of the HAART non-adherence phenomenon. This approach has been recommended elsewhere [18] and we have received a broader response from participants by using a comprehensive interview guide. A limitation of the study was having only one recruitment site, thus limiting the emergence of other system barriers jir.2010.0097 or facilitators attached to other site realities. Another limitation was the sample size. Although twelve is an acceptable number of participants for a descriptive study, it may not be enough to reach saturation of certain phenomena; such was the case of PHC recommendation barriers.ConclusionThe results of this study suggest the interconnection of HIV treatment adherence barriers at various system levels. Future studies on HIV treatment barriers should explore these interactions and investigate the possible synergistic effect on non-adherent.
