Livelihood Experiences and Adherence to HIV Antiretroviral Therapy among Participants in a Food Assistance Pilot in Bolivia: A Qualitative Study

Abstract

IntroductionHealth and development organizations increasingly promote livelihood interventions to improve health and economic outcomes for people living with HIV (PLHIV) receiving treatment with antiretroviral therapy (ART). In-depth understanding about how PLHIV make labor decisions in the context of treatment for HIV – and treatment decisions in the context of their livelihoods – is essential to guiding intervention design and developing hypotheses for future research on livelihoods and ART. However, few studies have explored the perspectives of PLHIV regarding integration of livelihoods and ART in urban, resource-limited settings.MethodsQualitative interviews explored the livelihood experiences of food insecure ART patients in four Bolivian cities (n = 211). Topics included work-related barriers to ART adherence, HIV-related barriers to work, and economic coping mechanisms. Themes were identified using content coding procedures, with two coders to maximize reliability.ResultsParticipants reported complex economic lives often characterized by multiple economic activities, including both formal and informal labor. They struggled to manage ART treatment and livelihoods simultaneously, and faced a range of interpersonal and structural barriers. In particular, lack of HIV status disclosure, stigma, and discrimination were highly salient issues for study participants and likely to be unique to people with HIV, leading to conflict around requesting time off for clinic visits, resentment from co-workers about time off, and difficulties adhering to medication schedules. In addition, health system issues such as limited clinic hours or drug shortages exacerbated the struggle to balance economic activities with HIV treatment adherence.ConclusionsImproved policy-level efforts to enforce existing anti-discrimination laws, reduce HIV-related stigma, and expand health services accessibility could mitigate many of the barriers discussed by our participants, improve adherence, and reduce the need for livelihoods interventions.

Barriers and Facilitators of Adherence to Antiretroviral Drug Therapy and Retention in Care among Adult HIV-Positive Patients: A Qualitative Study from Ethiopia

“…These factors have also been documented in other studies [8], [19], [22], [23], [25], [26], [27], [28]. Patients were lost to follow-up when they migrated to other places either inside or outside Ethiopia to find a job.…”

“…Patients also missed pills and stopped collecting repeat prescriptions from clinics when they could not afford to buy food, or when NGOs stopped supplying food rations. The negative impact of food insecurity on adherence has also been recognized in other studies conducted in sub-Saharan Africa [8], [27], [28]. Lack of job opportunities and food insecurity, while not exceptional to patients with HIV/AIDS, were exacerbated by the co-existence of other HIV-associated challenges such as stigma and discrimination, reduced physical activity, medication schedules, and indirect treatment costs.…”

“…The findings of several studies conducted in resource-limited settings have shown that major facilitators of ART adherence encompass social support, positive treatment outcomes, and life-long projects [5] , [6] , [7] . Factors such as cost of medications, access to health facilities, transport costs, and fear of stigma and discrimination are recognized barriers to adherence with ART [8] , [9] , [10] .…”

Severe food insecurity is associated with overweight and increased body fat among people living with HIV in the Dominican Republic

“…Food insecurity disproportionately affects households living in poverty since economic security is a key determinant of food security (Rose, 1999). Among people living with HIV (PLHIV), food insecurity is associated with reduced antiretroviral therapy (ART) adherence (Kalichman et al, 2014; Palar, Martin, Oropeza Camacho, & Derose, 2013; Young, Wheeler, McCoy, & Weiser, 2014), reduced viral suppression (Alexy, Feldman, Thomas, & Irvine, 2013; Wang et al, 2011), and increased morbidity and mortality (Anema et al, 2013; Anema, Vogenthaler, Frongillo, Kadiyala, & Weiser, 2009; McMahon, Wanke, Elliott, Skinner, & Tang, 2011; Semba & Tang, 1999; Weiser et al, 2011).…”

Supporting choices about HIV disclosure in the workplace: A cross-Canada survey of strategies

“…However, in most cases in Canada, disclosure of a specific diagnosis is not necessary to obtain accommodations. People living with HIV may also want to explain to supervisors and coworkers why they have health-related absences and need time off work for medical appointments [23]. Other people living with HIV may be considering workplace disclosure because they want to reduce the stress they feel in keeping a secret from their colleagues [24].…”