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Study Supports Importance of Patient Agency, Stability in HIV Treatment


Adherence to antiretroviral therapy (ART) can be improved by health care providers reinforcing ART dispensing models and creating ART models that promote situational stability, according to a new study.

Canadian researchers at the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS) have published an ethno-epidemiological study in PLoS One that supports the use of several strategies for improving adherence to antiretroviral therapy (ART) for people with HIV.

The study authors emphasized 2 recommended actions: (1) for providers to reinforce ART dispensing models that support patient agency and (2) for providers to create ART models that promote situational stability in cases where patients have adverse stressors like housing insecurity and inconsistent daily medication routines.

The goal of the study was to seek context for how key dispensing models affected ART adherence among people living with HIV (PLHIV) who used drugs and lived in low-income housing in Vancouver, Canada.

Participants in the study were required to be 18 years or older, be HIV seropositive, and have used illicit drugs, such as heroin or crystal methamphetamine, in the previous 30 days at baseline.

Thirty-one PLHIV were interviewed a maximum of 2 times at the ACCESS storefront research office. Participants ranged in ages from 29 to 61 years. Fifteen self-identified as women, 14 as men, and 2 as transgender, Two Spirit, or nonbinary. No participants refused to participate or dropped out of the study.

The investigators then imported all interview transcripts into qualitative data analysis software and analyzed them for commonalities in responses. They categorized HIV medication dispensing models into 3 classes—self-administration, daily delivery, and daily pickup—to characterize the impacts of the models.

“Participants reported missing HIV medications due to changes in illicit drug use (eg, frequency, source), regardless of treatment model, and that these changes in their drug use patterns and HIV treatment were shaped by social-structural–level factors (eg, housing vulnerability, lack of agency) that are known to impact ART outcomes,” the researchers wrote.

Being able to integrate ART into an established routine was key to supporting adherence, particularly for those who were responsible for self-administering their treatment each day. The authors noted, “More than other treatment dispensing models, participants emphasized that, under self-administration, adhering to medications was a conscious choice that they had to continue re-making daily.”

Although self-administration offered patients the greatest degree of agency in their HIV treatment, the findings did not indicate a need to incorporate a totally self-administered style of treatment across the board. Rather, the authors wrote that it is beneficial to provide participants a choice in the degree to which a regimented structure for ART dispensing is provided with respect to each participant’s own unique conditions and efforts.

The authors reported there was a notable degree of concordance in the participant interviews and suggested that further data collection with the group would have yielded few new insights.

They also noted that the findings must be considered alongside several limitations of the study. The study sample likely overrepresented PLHIV who are already well connected to health care services relative to the general population of PLHIV who use drugs in cities like Vancouver.

There were additional concerns about the study’s recruitment method excluding those who were unstably housed or not engaged in care or accessing social services.

The authors noted the underrepresentation of transgender, nonbinary, and Two Spirit participants in the study, who are disproportionately impacted by HIV relative to the wider population. The scope of the project also did not emphasize Indigenous participants’ general lived experiences, despite their overrepresentation in those selected for the research.

Nevertheless, the authors believe that their study reinforces a wide body of findings that recommend similar ways to improve ART outcomes.

“Building upon previous research with people who use illicit drugs on asserting agency in health care interactions, our findings underscore how PLHIV who use drugs seek to negotiate agency within, and across, different ART treatment frameworks in a way that that is sensitive to their own treatment needs,” they concluded.


Fleming T, Collins AB, Bardwell G, et al. A qualitative investigation of HIV treatment dispensing models and impacts on adherence among people living with HIV who use drugs. PLoS One. 2021;16(2):e0246999. doi:10.1371/journal.pone.0246999

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