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Improving Antiretroviral Therapy Adherence Among Patients With Complex Needs

Added on 16 May 2011
Last updated on 14 Jun 2011

Authors: By Sarah Arnquist, MPH; Reviewed by Sophie Beauvais and Christopher Shaw, RN

Nurses working in developed and developing countries confront challenges in promoting adherence to HIV treatment, particularly among patients with numerous, complex needs. Good adherence is important because it strongly predicts viral suppression, drug resistance development, disease progression, and death (Bangsberg, 2010). Adherence has also been shown to be associated with lower overall medical costs, as patients stay healthier and out of the hospital (Nachega, 2010). Through this online discussion, nurses working globally exchanged tools and lessons learned while trying to prepare patients to begin life-long medication adherence.

The discussion began with two case descriptions of immigrant patients at a Boston infectious disease clinic. Subsequently, nurses with work experience in the U.S., Ethiopia, Nigeria and South Africa offered suggestions to improve patient care. Nurses emphasized the need to conduct assessments related to treatment readiness, cultural backgrounds, and literacy. Participants shared tools and training curriculums, offered step-by-step guides for working with patients from other cultures and discussed the need to involve patients’ families and communities.

Key Points


  • Treatment readiness assessments should be performed before initiating patients on ART. The assessment should identify barriers, challenges, levels of understanding, and psychosocial needs.
  • Cultural Assessment should also be performed to examine patient characteristics, such as values, family and health-related beliefs, and social norms. Through such an assessment, nurses can gain insight and identify patient values and attitudes toward illness and health.
  • The structured system for treatment preparation at the AIDSRelief Program in Nigeria flows in the following manner: 1) The patient identifies a treatment supporter; 2) A community-based treatment support specialist visits the client at home before starting therapy to assess the living context; 3) If the client lives far away from the treatment facility, a plan for reliable transportation must be developed; 4) A group of HIV-positive treatment support specialists reach out to the clients at the treatment facility and in the community.

Building Trust, Support and Capabilities

  • Good adherence requires educating patients to become experts in their own care.
  • Visiting patients’ home environments facilitates trust building. Nurses should listen to their needs, fears, and goals to identify opportunities to overcome adherence barriers.
  • Nurses can support patient disclosure by walking them through the process and role playing to help them practice what to say. Helping patients develop a plan for support and offering to accompany the patient during disclosure may also help.
  • The iTEACH program in South Africa emphasizes community involvement prior to patients starting ART. Privacy laws in the U.S. prohibit discussing a patient’s diagnosis without his or her permission, but nurses should work on developing trusting relationship to help patients disclose their status so they are not living in isolation. Friends and family members can be taught how to help. Patients should be encouraged to join HIV-positive living communities or support groups. If patients feel they cannot disclose their status to their family and community due to high stigma, they should at least feel confident that their health care providers are available to help them.
  • Patients can benefit significantly from being linked to accompaniment programs, such as the Prevention and Access to Care and Treatment (PACT) Program.


  • Developing culturally sensitive picture guides for children or adults with low literacy can aid in education.
  • The HIV/AIDS Stigma Instrument-PLWA (HASI-P) developed by nurses at the University of California, San Francisco is one tool to facilitate initial patient assessments.

Key References

Enrich the GHDonline Knowledge Base
Please consider replying to this discussion with the following information

  • If you use a specific treatment readiness framework or assessment tool, please consider sharing it with the nursing community.
  • Do you have any additional examples of creative ways to promote adherence that could be exported for use in other countries? If so, please share in the community.

Download: 05_16_11_Nursing_Adherence_.pdf (36.7 KB)