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AIDS Care
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HIV/AIDS treatment adherence in economically better

off women in Colombia
a b c d
Marcela Arrivillaga , Andrew E. Springer , Monica Lopera , Diego Correa , Bernardo
e f
Useche & Michael W. Ross
a
Department of Public Health & Epidemiology, Health & Quality of Life Research Group,
Pontificia Universidad Javeriana Cali, Cali, Colombia
b
Michael & Susan Dell Center for Advancement of Healthy Living, University of Texas School
of Public Health-Austin Regional Campus, Austin, TX, USA
c
National Faculty of Public Health, University of Antioquia, Medellín, Colombia
d
Health & Quality of Life Research Group, Pontificia Universidad Javeriana Cali, Cali,
Colombia
e
Associate Researcher Health & Quality of Life Research Group, Pontificia Universidad
Javeriana Cali, Colombia
f
Center for Health Promotion and Prevention Research, School of Public Health Houston,
University of Texas, Houston, TX, USA

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 AIDS Care
2012, 1
7, iFirst

HIV/AIDS treatment adherence in economically better off women in Colombia

Marcela Arrivillagaa*, Andrew E. Springerb, Monica Loperac, Diego Corread, Bernardo Usechee and
Michael W. Rossf
a
Department of Public Health & Epidemiology, Health & Quality of Life Research Group, Pontificia Universidad Javeriana Cali,
Cali, Colombia; bMichael & Susan Dell Center for Advancement of Healthy Living, University of Texas School of Public Health-
Austin Regional Campus, Austin, TX, USA; cNational Faculty of Public Health, University of Antioquia, Medellı´n, Colombia;
d
Health & Quality of Life Research Group, Pontificia Universidad Javeriana Cali, Cali, Colombia; eAssociate Researcher Health
& Quality of Life Research Group, Pontificia Universidad Javeriana Cali, Colombia; fCenter for Health Promotion and
Prevention Research, School of Public Health Houston, University of Texas, Houston, TX, USA
(Received 21 June 2011; final version received 1 December 2011)

Studies on HIV/AIDS treatment adherence have been carried out in a limited number of geographic settings, but
few studies have explored it in people of higher socioeconomic status in Latin America. This qualitative study
explored and compared determinants of adherence behaviors among 52 HIV-positive Colombian women in
Downloaded by [Marcela Arrivillaga] at 08:55 24 January 2012

medium and high socioeconomic positions (SPs). Findings indicated that the two SP groups reported high
adherence behaviors related to taking medication, following a diet, and executing lifestyle changes in line with
healthcare providers’ recommendations. Nevertheless, differences were observed between the two groups. While
women with a medium SP disclosed their diagnosis, were empowered, and had acceptable access to economic
resources that resulted in favorable adherence, their better off counterparts tended to hide their status and made a
conscious effort to keep their adherence behaviors in secret due to HIV-related stigma. More studies on
adherence of people living with HIV/AIDS from high SPs should be conducted to better understand how
psychosocial support can be provided and to advance the knowledge of how and why adherence practices in these
groups are undertaken.
Keywords: adherence; socioeconomic position; gender; stigma

Introduction et al., 2004), data have been lacking about adherence

The HIV/AIDS epidemic is a global problem that
affects most regions of the world, with an increasing
frequency of diagnosed women. Worldwide, women
make up half of the people living with the virus,
and this percentage has been gradually increasing
(UNAIDS, 2008).
In the control of HIV, adherence to treatment has
been a priority because of its potential to extend life
expectancy and quality of life for affected people.
Lack of adherence could produce viral resistance,
progression to AIDS, and opportunistic illnesses
(Decock et al., 2001; Hofman & Nelson, 2006;
Johnson & Neilands, 2007; Park-Wyllie et al., 2007;
Righi et al., 2008; Wyss et al., 2004). Most of the
studies on adherence have been carried out in the
limited settings of Sub-Sahara Africa, the Dominican
Republic, and Haiti (Arregui, 2007; Behforouz,
Farmer, & Mukherjee, 2004; Hardon et al., 2007;
Koenig, Leandre, & Farmer, 2004). Although the
literature has indicated better rates of adherence
achieved by persons who have higher educational
and income levels (Carballo et al., 2004; Kleeberger
among economically better off individuals, including
women.
Given that an estimated 1.4 million people have
HIV in Central and South America, with rates
projected to increase (UNAIDS, 2010), research
from this region is needed to design strategies for
promoting adherence as well as providing social
support to those who have the virus. Colombia has
the third highest number of HIV/AIDS cases in the
region; the country’s level prevalence has shown a
linear trend since 1990 and currently falls between
0.6% and 0.7%
approximately 77,567
210,972
cases
(Ministry of Social Protection, 2009; WHO
& UNAIDS, 2008). In recent years the infection rate
among women has been found to be increasing from
35,000 in 2001 to 50,000 in 2009; currently, women 15
years of age and older represent 28.12% of a total of
cases (Ministry of Social Protection, 2009; UNAIDS,
2010). Regarding antiretroviral coverage, in Colom-
bia, 21,000 men and women are receiving treatment,
while another 54,000 need it (WHO & UNAIDS,
2008). In this setting, this study explores and com-

*Corresponding author. Email: marceq@javerianacali.edu.co

ISSN 0954-0121 print/ISSN 1360-0451 online

# 2012 Taylor & Francis
http://dx.doi.org/10.1080/09540121.2011.647678
http://www.tandfonline.com
 2 M. Arrivillaga et al.
pares determinants of adherence behaviors; particu-
larly among economically better off HIV-positive
Colombian women.
Methods
The study was conducted in Cali, Colombia, South
America between 2009 and 2010. A qualitative
research method with focus groups discussions
(FGDs) was applied. The research study was ap-
proved by ethical committees of the Colombia Na-
tional University, the Javeriana University, and the
health care centers where the women were recruited.
Participants
Downloaded by [Marcela Arrivillaga] at 08:55 24 January 2012
HIV-positive women were identified through health
care center registers with the following inclusion
criteria: receiving antiretroviral therapy (ART),
age]18, not pregnant, and a classification of med-
ium or high socioeconomic position (SP) according to
the country’s official socioeconomic classification.
Out of a total of 185 women registered in four
healthcare centers, 68 (36%) were eligible. Of these
68, 52 agreed to participate in the FGDs. To control
selection bias, women were recruited from compre-
hensive HIV care programs in places directed toward
women of all socioeconomic status levels. To begin
the recruitment process, women were invited with an
initial phone call made directly by personnel from
the respective health care center. Finally, all of the
women were formally recruited by a second phone
call following strict protocols for ensuring their
confidentiality.
Women in the medium SP were considered social
level 3 or 4 by the official system of the Colombian
Government. They had a technical or undergraduate
educational level and were affiliated with a basic
health care plan. Their job/occupational profiles
included: housewives, small business owners, self-
employed with a steady income, employees at private
or public entities, or self-employed professionals.
They earned roughly US$800 monthly, had access
to credit and owned property. Women with a high SP
were characterized by the Colombian Government as
social level of 5 or 6. They had a postgraduate
education, were affiliated with a basic health care
plan complemented by additional expanded private
health insurance. Their job/occupational profiles
included: housewives, business owners or employees
in private, or public entities with directive functions.
They earned roughly US$3000 monthly, had access to
credit, and owned more than one property.
Procedures
After signing an informed consent, the women
participated in one of the five FGDs; each group
comprised 10 women. The FGDs were carried out in
four phases: (1) Introduction and explanation of the
aim of the FGD, the group norms, and dynamics. (2)
Description of the adherence concept
the extent to
which a person’s behavior
taking medication, follow-
ing a diet, and/or executing lifestyle changes

corresponds with agreed recommendations from a
healthcare provider
(WHO, 2003, p. 18). (3)
Discussion of four basic themes: adherence behaviors,
living conditions associated with adherence, and
barriers and facilitators for adherence. These themes
were explored through the main open-ended ques-
tions; the women were asked to express their degree
of agreement or disagreement with a specific point of
view. (4) Conclusions of the FGD. Data were
collected to complete the criteria of theme saturation.
Data analysis
Data obtained in the FGDs were digitally recorded
for later transcription and analysis. Content analysis
(Deslauriers, 1991) consisted of two phases: (1) Data
deconstruction and (2) Data reconstruction and
synthesis. In the first phase, after a systematic reading
of the transcriptions, we transformed data into codes.
Atlas Ti v5.2 software was used, resulting in the
identification of 67 quotation groupings based on
35 codes. Afterward, we proceeded to analyze the
initial data codification obtained from the text; for
this analysis, we considered the frequency of the
codes. In the second phase, we organized codes in
specific categories, identifying recurrent patterns to
obtain emergent categories that were described and
interpreted. In this process, we maximized differences
dividing data into groups and later synthesized codes
into dominant themes. To ensure the validity and
reliability of data, we carried out the following steps:
(1) Discussion sessions between researchers to com-
pare original transcripts and the analysis about
emergent categories; (2) Reading and validation of
the content analysis with 10% of the participant
women; and (3) Comparison of researcher field notes
with those of the participant observer.
Results
Sociodemographic characteristics
Out of a total 52 women, 32 (61%) were classified as
belonging to a medium SP and 20 (39%) as belonging
to a high SP. The mean age of the study participants
was 34 years; other sociodemographic characteristics
 AIDS Care 3

are shown in Table 1. Regarding adherence, 48 Table 1. Sociodemographics characteristics. Women in

women (94%) reported taking medication, following medium and high socioeconomic positions, Cali, Colombia,
a diet, and executing lifestyle changes 95% of the time 2010 (n 52).
in accordance with health care providers’ recommen- %
dations; four women (6%) indicated that they took
their prescribed medication but failed to implement Socioeconomic ‘‘Stratum 3 or 4’’ or medium 61
lifestyle changes. stratum socioeconomic position
After content analysis, the following were the two ‘‘Stratum 5 or 6’’ or high 39
main categories that emerged: socioeconomic position
Marital status Married and Common law 16
Single 54
‘‘EMPOWERED ADHERENCE’’ in women of Separated or divorced 20
Widow 10
medium SP
Education Technical 24
Some women in the medium SP expressed that they Undergraduate 37
were economically independent and primarily respon- Postgraduate 39
sible for their homes. Others indicated that they Housewives 16
generated income from work to support their Job and Small business owners 14
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families. On receiving the HIV diagnosis, women
reported that the initial impact could be disconcert-
ing, resulting in anger, and sadness. Soon, they coped
with the treatment, conscious of the benefits of
staying healthy with favorable adherence. These
women had socioeconomic advantages, but they
also had pressures to meet economic and social
obligations and could not afford the time to delay
or refuse treatment.
Women with full or partial economic indepen-
dence and who communicated their diagnosis to their
families kept active roles as homemakers. They
expressed feeling empowered, able to cope with their
diagnosis and to developing self-care behaviors.
Economic power let working women with their own
income exercise autonomy and self-efficacy as women
capable of facing their HIV-positive status.
The SP of this group of women permitted them
access to formal education and the development of
skills to understand the complexity of the ART in
addition to the importance of properly managing the
disease. Their educational background facilitated this
knowledge and promoted practices to seek out
detailed information about HIV/AIDS once they
were diagnosed. They developed information-seeking
skills that allowed them to select trustworthy infor-
mation on HIV, attend workshops and conferences,
and surf the Internet. The benefits of their educa-
tional background derived from their SP facilitate
them to take up adherence behaviors. Also, this
group expressed a high level of self-efficacy to
negotiate their treatment with the doctors, under-
stand their medication, correct doses, side effects,
viral loads, and CD4 count.
Another characteristic of the empowerment of
this group was the habit of defending their rights to
access to treatment. They demanded a response from
the health system even when they might have faced
occupational Self-employed with a steady 17
profile income
Employees at private or public 18
entities
Self-employed professionals 4
Business owners 12
Employees in private or public 19
entities with directive functions
HIV-positive Yes 17
children
rejection. Disclosing their condition more readily
than less advantaged women, they did not shy away
from seeking help from non-government organiza-
tions (NGOs). Fear of rejection and discrimination
from the healthcare providers did not interrupt their
treatment, and their HIV-positive diagnosis was
accepted by them as would be their acceptance of
any other chronic disease. Defending and advocating
for their healthcare rights was also tied to their
knowledge of the health system, along with commu-
nity support networks. They learned about legal
issues, how to navigate the governmental bureaucracy
and administrative paperwork, and how to take legal
actions when the treatment is interrupted. These
skills allowed them to succeed in getting medical
attention and timely and continuous access to ART.
‘‘ADHERENCE IN HIDING’’ among women of
high SP
Women classified as having a high SP enjoyed greater
access to economic and other resources that generally
led to a greater tendency for strong adherence
practices. However, adherence was not confronted
without barriers. Higher-income women coped with
HIV and with an expected social role that may have
created more difficulties in accepting their diagnosis
 4 M. Arrivillaga et al.
as compared to women with a medium SP. Confront-
ing these unique sources of stress could eventually
lead to threats to their health.
Trying to avoid HIV-related stigma, higher in-
come women attempted to bypass the healthcare
system. First of all, these women preferred to pay
directly for HIV treatment. In this way, they avoided
having their diagnosis registered with the national
healthcare system. As they could afford private
appointments, frequently they also looked for specia-
lists in Colombian cities other than their cities of
residence; this strategy minimized threats to the
confidentiality of their diagnosis. For this group,
the economic cost of healthcare was less important
than keeping the secret of their diagnosis.
In contrast to women from a medium SP, higher
income women tended to think of HIV/AIDS more as
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a shameful sickness and less as a life-threatening
disease. For them, ‘‘being sick’’ also meant depending
on others and needing to get their help and support.
Thus, relying on others while sick was counter to their
personal beliefs as independent professional women.
They also harbored strong HIV-related stigma con-
victions about discrimination, fear of rejection, and
the collective pity often triggered by a HIV-positive
diagnosis.
These fears reported by higher income women
were based on experiences of overhearing friends and
acquaintances making negative comments in their
own social circles in an attempt to destroy others with
salacious stories and hurtful gossip. They also feared
that their families would reject them once they
discovered their HIV-positive status, calling into
question their sexual practices. Revealing their infec-
tion would also break existing family relations and
destroy the image these women had about themselves.
Fear of HIV-related stigma and discrimination led
this group to use multiple strategies to disguise their
HIV-positive status. To keep their diagnosis secret,
they cultivated their physical appearance, social
image, and personal aesthetics. The need to present
a socially appropriate image was one of the main
motivations for adherence. They were conscious of
the need to protect their health, but they also were
desperately trying to hide their HIV from their
families and their social circles. Covering up HIV
status in the event of sickness, hospitalization, or
death was a primary concern. Under no circum-
stances would they join support groups or NGOs.
Although all of the above limited their possibi-
lities of receiving comprehensive care, the secret of
their diagnosis did not interfere with adherence. The
resulting emotional suffering and stress caused by
their hiding a potentially deadly diagnosis could be
overwhelming and eventually lead to the deteriora-
tion of their mental and physical health.
Discussion
In this study, findings showed that women in medium
and high SPs engaged in adherence behaviors for the
management of HIV. However, distinct differences
were observed between the groups.
In women from a medium SP, acceptable access to
economic resources empowered them and resulted in
favorable adherence. Economic empowerment has
been found to be one of the six areas of empowerment
for HIV-positive women, along with socio-cultural,
familiar/interpersonal, legal, political, and psycholo-
gical (Malhotra, Schuler, & Boender, 2002). Empow-
erment in the economic sphere includes control of
income and home resources (Malhotra et al., 2002).
This empowerment helps explain good practices
toward adherence of women in medium SP and aids
them in defending their right to an uninterrupted
supply of medication from the Colombian health care
system.
In line with other researchers, our findings under-
scored the importance of the woman’s control of her
own money as a positive behavior on mental and
physical health. Economic empowerment also has
been associated with increased self-esteem, autono-
my, problem-solving, and decision-making skills
(Ashburn, Kerrigan, & Sweat, 2008; Kim et al.,
2007; Kim, Pronyk, Barnett, & Watts, 2008; Mohin-
dra, Haddad, & Narayana, 2008). In addition to the
important role of economic determinants, our find-
ings reinforced the fundamental role of educational
background in providing women the tools with
which to take care of themselves as well as obtain
information and resources for the management of
their treatment. Social capital, economic resources,
property rights, access to quality education, and the
opportunity to have a voice in decision-making at all
levels are sources of empowerment for HIV-positive
women (Dworkin, Kambou, Sutherland, Moalla, &
Kapoor, 2009; Ehrhardt, Sawire, McGovern,
Peacock, & Weston, 2009; Gupta, 2000).
Regarding women with a high SP, they can count
on the benefits of their social status and have
sufficient economic, cultural, and educational capital
to draw on. This group had a deep conviction about
the importance of adherence and was ready to make
use of all their personal skills and material resources
to cope with the treatment. Nevertheless, their
adherence was related to keeping their diagnosis
secret and avoiding stigma. While women with a
medium SP disclosed their diagnosis and had explicit

behaviors to defend their treatment, their better off
counterparts hid their status and kept their treatment
a secret. Paradoxically, secretive adherence practices
had the goal of conserving not only their health but
also their physical image, appearance, and personal
aesthetics. For them, the diagnosis was a pivotal
point and implied a redefinition of their identity
(Carr & Gramling, 2004; Pecheny, Manzelly, & Jones,
2007). These women reflected every prejudice and
rejection learned from society on themselves, which
gave way to irrational fears while silence took control
of their lives (Arregui, 2007). As shown by other
authors, not sharing the diagnosis was to avoid
embarrassment and shame, keeping their daily rou-
tine, avoiding, fear of rejection, and being an object
of ridicule or spiteful commentaries in their social
circles (Pecheny et al., 2007).
Downloaded by [Marcela Arrivillaga] at 08:55 24 January 2012
The overwhelming emotional burden for them
represented potential risks to their health and posed a
latent threat to adherence. Some authors demon-
strated that secretiveness leads to isolation, family
problems, stress, anxiety, depression, and guilt (Ruiz-
Torres, Cintrón-Bou, & Varas-Diaz, 2007; Thi et al.,
2008), and that along with the appearance of side
effects can have a negative influence on adherence
(Rao, Pryor, Gaddist, & Mayer, 2008; Rintamaki,
Davis, Skripkauskas, Bennett, & Wolf, 2006). Others
have suggested that revealing their true status elim-
inates rituals of adherence (Serovich, McDowell, &
Grafsky, 2008) and is associated with better quality of
life and the use of social networks (Emlet, 2006; Li,
Lin, Ji, Sun, & Rotheram-Borus, 2009). Regardless,
some data indicate the opposite and are not always
associated with obtaining social support (Smith,
Rossetto, & Peterson, 2008); in the case of people
with HIV/AIDS with a high SP, the evidence about
the benefits of disclosure is limited.
Health services should provide a network of these
women to create mechanisms for emotional, instru-
mental, and informational support. We also recom-
mend further analysis of the effects of stigma and
cultural beliefs associated with social status on
adherence in the HIV/AIDS population with high
SP. It is also advisable to study the effects of
disclosure in obtaining social support for adherence.
The differences in the experience of stigma for people
from diverse cultural backgrounds should be consid-
ered (Rao et al., 2008).
Several limitations of the study merit mention.
First, we could not analyze the associations between
immunological variables and adherence due to ethical
and recruitment limitations that did not allow us
access to their medical records. Second, information
about adherence based on self-reporting could be
biased by answer desirability and memory issues.
AIDS Care 5
Also, the authors recognized that because the women
are economically capable of making use of social and
health services some of them could underestimate the
problems of adherence. And third, from those we
invited to participate there were 14% who did not
join the study; so it is possible that differences in
adherence existed among this social group. Because
of these limitations and the exploratory nature of the
study, further insights on adherence issues among
better off women are needed.
Finally, based on these results as well as the
findings from previous studies on adherence among
Colombian women (Arrivillaga, 2010; Arrivillaga,
Ross, Useche, Alzate, & Correa, 2009; Arrivillaga,
Ross, Useche, Springer, & Correa, 2011), policy-
makers and health care providers should: (1) design
appropriate protocols for providing comprehensive
care; (2) guarantee access to medications and health
care services; (3) reduce HIV stigma from health care
providers; (4) uphold existent norms related to
mandatory confidentiality regarding HIV diagnosis;
and (5) provide technical and financial support to
NGOs. We recommend conducting further research
on adherence of people with the virus from higher SPs
to better understand how psychosocial support can be
provided and to advance the knowledge of how and
why adherence practices in these groups are under-
taken.
Acknowledgements
This study was conducted with funding from the Pontificia
Universidad Javeriana Cali, Colombia. The authors also
acknowledge the support of Paula Andrea Hoyos, Re-
searcher of the Health and Quality of Life Research Group
of the same university (COLCIENCIAS, Colombia, Cate-
gory A), who participated in the data collection.
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