Capitalising further on the benefits of antiretroviral therapy (ART) for individual   treatment requires an improved understanding of the psychological processes   that may affect optimal ART adherence among people living with HIV. We   examined internalised HIV/AIDS-related stigma and body appreciation as   mediators of the association between self-esteem and ART adherence among   young people living with HIV (YPLHIV). A sample of 76 YPLHIV (Mage = 19.36,   s.d.age = 2.56; male 56.58%) residing in an HIV hyperendemic region of South   Africa completed self-report measures of self-esteem, internalised   HIV/AIDS-related stigma, body appreciation, and ART adherence. Path-analytic   mediation modelling was performed to test for direct and indirect effects   linking self-esteem with ART adherence. Results of serial mediation analyses   indicated that self-esteem and ART adherence were indirectly associated   through a two-step path of internalised HIV/AIDS-related stigma and then body   appreciation, as well as a one-step path through internalised   HIV/AIDS-related stigma. The results provide preliminary support for   internalised HIV/AIDS-related stigma and body appreciation as mechanisms   underlying the association between self-esteem and ART adherence.   Implications of the findings for promoting ART adherence among YPLHIV are   discussed.

Self-esteem and antiretroviral therapy adherence among young people living with HIV: An exploratory serial mediation analysis

Participants

The   sample comprised 76 (56.58% male) seropositive young people residing in the   city of Durban, South Africa. Durban is located within the province of   KwaZulu-Natal, which has the highest HIV prevalence rate in the country.37   Participants ranged from 15 to 24 years of age (Mage=19.36, s.d.=2.56) and   identified racially as African (82.89%) or coloured (17.11%). A majority of   the sample had fulfilled high school equivalency requirements (67.11%) or   completed post-secondary education (28.95%). A small proportion of the   participants had not completed any formal education (3.95%). Almost half of   the sample (52.63%) indicated that they had acquired HIV after birth from a   source other than their mother (i.e. horizontal infection), and the remainder   (47.37%) reported that they had been infected through mother-to-child   transmission (i.e. vertical infection).

Measures:

Rosenberg Self-Esteem Scale

The   Rosenberg Self-Esteem Scale (RSES) is a 10-item measure of self-respect and   self-acceptance. Items (e.g. ‘I feel that I am a person of worth, at least on   an equal plane with others’) are rated using a fourpoint response scale (1 =   Strongly disagree; 4 = Strongly agree), half of which are reverse scored. In   this study, responses to all items were aggregated for a total raw score   (range: 10 to 40). Findings of various studies support the construct validity   of the RSES.38,39 Estimated internal consistency reported for the RSES in   prior research has been ≥0.80.40

Internalised AIDS-Related Stigma Scale

The Body Appreciation Scale-2 (BAS-2) contains 10 items that measure a person’s   perceptions of their body (e.g. acceptance, appreciation, inner positivity)   and attention towards their body’s needs through the adoption of healthy   behaviours.43 Participants rate the items (e.g. ‘I feel good about my body’)   using a five-point response scale (1 = Never; 5 = Always). Item responses are   summed for a total score ranging from 10 to 50. Higher scores indicate   greater levels of body appreciation. The BAS-2 has been cross-culturally   validated in samples from diverse countries (e.g. China, England).   Previous studies have reported internal consistency values of ≥0.80 for women   and men44, and evidence supports the convergent, incremental, and   discriminant validity of the BAS-243.

Morisky Medication Adherence Questionnaire

The   Morisky Medication Adherence Questionnaire (MMAS-8) comprises eight items   that assess patient adherence to medication for chronic conditions. The first   seven items (e.g. ‘When you feel like your symptoms are under control, do you   sometimes stop taking your medicine’) are rated using a dichotomous response   format (0 = Yes; 1 = No). A five-point response format is used to rate the   final item (e.g. ‘How often do you have difficulty remembering to take all   your medicine’), which is transformed to a dichotomous score prior to   aggregation of item responses (0 = A; 1 = B–E). In this study, participants   completed the MMAS-8 by referencing their adherence to ART medication. We   aggregated responses to each of the MMAS-8 items for a total score ranging   from 0 to 8, with higher scores reflecting greater adherence to ART. Evidence   supports the psychometric utility of the MMAS-8 as a valid and reliable   measure of medication adherence46, including ART adherence47. Previous   research has reported internal consistency values of ≥0.75 for the MMAS-8,   and the findings of several studies support the construct validity of the   measure.

Procedure:

Ethical   approval for this study was granted by the Humanities and Social Sciences   Research Ethics Committee of the University of KwaZulu-Natal (HSS/0522/018D).   Written permission was acquired from a local HIV youth centre to access   YPLHIV who received ART from the organisation. A purposive, convenience   sampling approach was used to recruit participants. Specifically, YPLHIV who   presented at the youth centre to collect their monthly medication were   invited by a team of researchers to participate in this study. Interested   individuals were directed to a private administrative office where they were   initially given details about the study purpose, the participation   procedures, and ethical considerations (e.g. anonymity, confidentiality).   Those who agreed to participate were invited to provide their written   informed consent. With the assistance of the nurses at the youth centre,   parents and legal guardians of potential participants below 18 years were   informed of the research. Written parental consent was obtained on behalf of   all legal minors who indicated their interest in participating. Written   assent was also obtained from legal minors. The measures were administered in   English, which participants completed in an office provided by the youth   centre. The research team was present and available to address any questions   or issues that arose during the course of the subjects’ participation.

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