Adherence Strategies

HIV patients' moods, social support have impact on medication adherence

Study provides stress and coping model

Investigators have found that HIV-infected patients who use an avoidance-oriented coping strategy and who have poor social support and a generally negative mood have poorer medication adherence.1

"What we were trying to do is determine whether the idea of stressful events had an impact on the extent to which men and women who were HIV positive adhered to their antiretroviral regimen," says Maria M. Llabre, PhD, a professor of psychology at the University of Miami in Coral Gables, FL.

"How individuals coped with stress was a key factor because possibly one way in which you could modify individuals' behavior was to encourage them to cope in a particular way or to facilitate a particular coping style," Llabre explains.

The study found that negative mood, social support, and coping strategies all were related to adherence, she says.

"We tested a model that identified coping as a mediator, linking negative mood and social support to adherence and that model was consistent with the data," Llabre says. "For example, individuals with low levels of support might be inclined to use denial as a way of coping, and then that denial might make them less likely to adhere to the medication."

Researchers measured coping strategies using the five 4-item scales from the situational version of the COPE Inventory, asking participants to choose answers that described how they dealt with HIV problems. Another measure used was the Profile of Mood States (POMS), which is a 65-item 5-point adjective rating scale, and the measure for social support was the Social Provisions Scale (SPS) and the Tangible Support scale from the Interpersonal Support Evaluation List (ISEL).1

For medication adherence, investigators used self-report and electronic monitoring, and viral loads were collected at all assessment appointments.1

"People who measured high on the coping strategy of denial and the behavioral disengagement scale tended to adhere less," Llabre says.

"One goal was to see whether these psychosocial variables predicted adherence because the idea then would be to modify some of the psychosocial variables and indirectly improve adherence," she says.

"We also studied what we referred to as positive ways of coping," Llabre says.

For instance, there was a scale of active coping, a scale that looked at acceptance, and a scale that looked at finding benefits in a bad situation, Llabre says.

"But when we looked at those they didn't predict adherence in our sample," Llabre says. "In other samples they have been shown to predict adherence, but we didn't find that in our data."

A possible reason for this result could be that the scales the investigators used were more positive coping than positive active ways, and it's the more active measures that relate to adherence, Llabre notes.

The measures for negative coping strategies would include these kinds of items:

  • The measure for denial states, "I pretend it has not really happened."
  • In the behavioral disengagement scale, one item says, "I reduce the amount of effort I put into solving the problem."

People with these types of negative coping strategies have the idea that they don't have to deal with problems, Llabre says.

"Instead of using the coping strategies separately on separate scales, we put them together in a factor which we call avoidant coping," she explains. "But denial is more of the way a person thinks about it, where behavioral disengagement is more the way a person acts on it."

The study also found a very strong relationship between adherence and viral load, which highlights the importance of educating HIV patients about the need to adhere to their antiretroviral therapy, Llabre says.

"The data we used for this study came from an intervention study," Llabre says. "We felt it was important to have participants meet with a pharmacist when they came to get their refills, rather than to just get a prescription."

Part of the intervention involved probing what may have been some barriers to adherence, Llabre adds.

"We do believe that piece is important because here you have someone who can serve as not only a support person, increasing the social support aspect, but you can also identify what might be other individual characteristics that might be preventing that person from adhering," Llabre says. "So if that could be incorporated into the treatment of HIV/AIDS, we think that would be a valuable piece."

Meantime, the study suggests that it's important for clinicians to test HIV patients for negative mood, social support, and avoidant coping strategies to identify those who might additional adherence support, she says.

"A case worker could be trained to incorporate the pharmacy interview or a pharmacist could incorporate the coping strategies interview," Llabre says.

"Another point of the study is that adherence is a variable, so to measure it reliably, you have to measure it multiple times and use different methods," Llabre says.

"One of the reasons we were able to detect adherence is because we used multiple approaches to adherence," Llabre explains. "So you need to keep in mind that just asking the patient once about adherence will result in a lot of error in the information."


  1. Weaver KE, et al. A stress and coping model of medication adherence and viral load in HIV-positive men and women on highly active antiretroviral therapy (HAART). Health Psych. 2005;24(4):385-392.