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Open Access
BMC Public Health
Factors inuencing adherence
toanti‑retroviral therapy inamazonian
indigenous people living withHIV/AIDS
Félix Valenzuela‑Oré1*, Yolanda Angulo‑Bazán1, Lucy D. Lazóriga‑Sandoval1, Norma L. Cruz‑Vilcarromero2 and
Cecilia R. Cubas‑Sagardia2
Abstract
Background Indigenous communities in Peru has been historically affected by high mortality rates attributable
to HIV‑AIDS infection, associated with a low access to health services, and socio‑cultural barriers. In this context,
the study aimed to describe factors associated with antiretroviral treatment adherence in people from Awajun and
Wampis indigenous communities, living with HIV‑AIDS in a Peruvian Amazonian region.
Methods A cross‑sectional study was completed with a consecutive sample of people from indigenous communi‑
ties (Awajun or Wampis) living with HIV, who were receiving antiretroviral treatment for at least the last three months.
Participants were recruited between October 1 and December 30, 2021, from four districts of Bagua and Condorcan‑
qui provinces in the Amazonian region. An ad‑hoc questionnaire was used to collect information about demographic,
economic, and socio‑cultural factors and access to health services. The Simplified Medication Adherence Question‑
naire (SMAQ) was used to evaluate adherence to antiretroviral therapy. Multivariate logistic regression analysis with
backward stepwise was performed to explore factors that might influence adherence.
Results Of the 208 participants, 28.8% reported complete adherence to antiretroviral treatment. The multivariate
logistic regression showed that occupation (aPR: 1.86; 95%CI 1.15–3.02), economic income (aPR: 0.64; 95%CI 0.41–
0.99), and adverse reactions to antiretroviral therapy (aPR: 0.36; 95%CI 0.18–0.70) were related to complete adherence
to medication.
Conclusion Only a third of participants reported complete adherence to antiretroviral therapy. Factors associated
with adherence to antiretroviral medication were related to socioeconomic conditions and adverse reactions to the
therapeutic scheme. Interventions to improve adherence in indigenous people living with HIV should consider these
factors in order to develop effective implementation strategies.
Keywords Adherence, HIV‑AIDS, Indigenous populations
*Correspondence:
Félix Valenzuela‑Oré
fvalenzuelao_12@yahoo.es
Full list of author information is available at the end of the article
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Valenzuela‑Oréetal. BMC Public Health (2023) 23:497
Background
e introduction of highly active antiretroviral therapy
(ART) has converted HIV infection from a terminal
disease to a treatable chronic disease. However, even
though ART improves the clinical, immunological, and
viral response, it requires maintaining a high level of
adherence to the prescribed therapy due to the danger
of an increase in viral activity and the development of
resistance to these drugs [1]. In recent years, non-adher-
ence to ART has become a complex public health prob-
lem with many associated factors that are related to the
social, economic, and cultural context of people living
with HIV. e World Health Organization (WHO) sug-
gests that these factors can be classified into four dimen-
sions: characteristics of the therapeutic scheme, patients’
characteristics, the relationship between healthcare
providers and patients, and the proper characteristics
of health systems. In the patient’s characteristics, one of
the most important factors are the belief systems about
health and disease that people should have due to their
sociocultural context [2].
Indigenous populations are one of the groups most
affected by the consequences of HIV infection and lim-
ited access to healthcare. Previous research has found
that indigenous populations have higher rates of incom-
plete adherence or complete discontinuation of ART
compared to the general population, possibly due to
factors related to their cultural uniqueness and their
views or interpretations about disease and conventional
treatments, as well as social aspects such as geographi-
cal barriers, access and availability of monitoring, etc
[3–5]. us, this situation suggests that public health
strategies to control the transmission of HIV in indig-
enous populations should be developed using a multi-
level approach based on human rights and integrating
traditional practices that can help reduce vulnerability
to transmission [6].
Peru is one of the Latin American countries with the
largest number of indigenous populations in the region.
According to official records, in 2017, there were 44
indigenous populations in 2703 communities at the
national level [7]. On the other hand, the epidemiology of
the HIV/AIDS infection in Peru still has characteristics
of a concentrated epidemic, with an estimated prevalence
of 0.3% in adults older than 15 years, an incidence rate
of 0.20 per 1000 inhabitants, with approximately 1000
deaths per year [8, 9]. Awajun and Wampis are Amazo-
nian indigenous populations, who represent 35.8% of the
total indigenous population affected by sexually trans-
mitted diseases, including HIV infection [7].
e Amazonas Region concentrates 13.4% of the
Peruvian indigenous communities, with an impor-
tant presence of Awajun and Wampis populations.
According to statistics from the Regional Health Direc-
tion, the districts with the most presence of Awajun
and Wampis populations report more than 70% of HIV
infection cases from the entire region [10]. ere is
some preliminary evidence which suggests that the con-
ception and social representations of health and disease,
especially in the case of HIV infection in people belong-
ing to these indigenous populations, strongly influence
the behaviors that they finally present before the health
interventions that the conventional health system tries
to impose [11–13]. However, there has been no evi-
dence found related to factors influencing ART adher-
ence in these populations. erefore, this study aimed
to describe factors associated with antiretroviral treat-
ment adherence in people from Awajun and Wampis
indigenous communities living with HIV-AIDS in four
districts from a Peruvian Amazonian region.
Methods
Study design andparticipants
is was a cross-sectional study that included people
living with HIV, who were over 18 years old, from Awa-
jun or Wampis communities, who were living in the dis-
tricts of Santa María de Nieva, El Cenepa, Río Santiago,
and Imaza (Amazonas Region-Condorcanqui and Bagua
provinces), and who had an ART prescription for at least
three months before the survey application. People who
had not received ART in the last three months because
of supply or logistical problems, previous failure of ART
or ART resistance, or who could not express themselves
or did not sign the informed consent form were excluded
from the study. Participants were included using a non-
probabilistic sampling by convenience.
Participants were recruited between October 1 and
December 30, 2021. In this context, according to medi-
cal records reviewed before the survey application, there
were 292 people living with HIV in the four districts that
would be evaluated in the study. e cases were distrib-
uted as follows: 82 in Santa Maria de Nieva district, 104
in Cenepa district, 42 in Rio Santiago district, and 64 in
Imaza district.
e study was approved by the Ethical Review Board
from the Instituto Nacional de Salud-Peru (RD N°
065-2020-DG-OGITT-OPE/INS). An informed consent
process was applied in the local language, explaining the
study’s aims and participation implications to the partici-
pants. Only participants who signed the informed con-
sent form were included in the study.
Assessment ofART adherence
ART adherence in last three months were evaluated with
the Spanish adapted version of Simplified Medication
Adherence Questionnaire (SMAQ) [14]. e SMAQ has
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Valenzuela‑Oréetal. BMC Public Health (2023) 23:497
been used in previous research [15] and as a monitor-
ing instrument in health public services in Peru [16]. e
questionnaire has six items with dichotomous answers
(Yes/No):
1. Do you ever forget to take your medication?
2. Did you always take your medications at the right
time?
3. Do you ever stop taking your medicine if you feel
sick?
4. Did you forget to take your medication over the
weekend?
5. I have not taken more than two doses in the last
week.
6. Did you forget to take the medicine more than two
days, in the last three months?
It was considered as a “non-adherent” anyone who had
a positive answer to any of the six questions. For the last
two questions, a positive answer was considered when
the participant indicated forgetting to take medication
for two or more doses in the last week, or for more than
two days in the last three months.
Assessment ofpossible associated factors
Data related to personal characteristics (age, gender,
civil status, educational level, occupation, religion,
monthly income, alcohol, tobacco or drug consump-
tion, family members and migration), clinical features
(disease time, risk population, opportunistic infections),
factors related to ART (therapeutic scheme, adverse
events), sociocultural factors (disease conceptualization,
medicinal plant use, attention by traditional medicine
agent, familiar support, social support, stigmatization,
and discrimination) and healthcare access (healthcare
insurance, time to the nearest health centers, transport
expenses to health centers, expenses in ART medica-
tions) were evaluated by an ad-hoc format developed by
the research team based on a previous literature review
(view Supplementary Material) [13]. at instrument
was previously validated by experts.
Data about social support and familiar support were
collected with a Likert scale with five categories (very
well, well, regular, bad, very bad), according to the con-
cept proposed by the national framework of integral
attention of people living with HIV, developed by the
Ministry of Health (Peru) [17]. In the same way, data
about clinical features and ART schemes were collected
according to the recommendations of the same docu-
ment (view Supplementary Material). Additionally, infor-
mation about ART features was corroborated with a
review of medical records in local primary care centers.
Data collection procedures
Previously, before conducting surveys, the researchers
collaborated with the regional health direction, health
networks, and primary care centers. ey were informed
about the study and were asked for their cooperation in
providing information about the medical records and
locations of people living with HIV from Awajun and
Wampis communities.
On the other hand, the researchers made official com-
munications with the provincial municipality and com-
munal authorities (“apus”), who signed the collective
informed consent form. At this point, eight local health
professionals with experience in healthcare for these
indigenous communities were identified and trained to
collect data using validated instruments.
e participants were recruited by appointments at the
nearest primary health care center, where trained pro-
fessionals identified potential participants who met the
selection criteria. is process was conducted under the
supervision of the representative of the regional health
direction and the research team.
Each primary health care center was equipped with an
appropriate space to ensure privacy and build confidence
with potential participants. If any participant wanted to
be surveyed in their home, a visit was scheduled, ensur-
ing privacy and confidentiality. e local language was
used during data collection to ensure the quality of the
information.
Statistical analysis
A codified database was created in Microsoft Excel 2016
by two independent typists who were not part of the
research team. Registries with inconsistent or missing
data were excluded from statistical analysis. Descriptive
measures (frequencies, percentages, means or medians,
and standard deviation/interquartile range) were calcu-
lated according to the nature of variables (qualitative or
quantitative).
After that, a bivariate analysis was performed to evalu-
ate the association between possible factors (personal
characteristics, clinical features, factors related to ART,
sociocultural factors, and healthcare access) and adher-
ence to ART. Fisher’s Exact Test or Chi Square Test were
used for qualitative variables; and Student’s t-test for
independent data or Mann-Whitney U for quantitative
variables.
A multivariate analysis was developed through multiple
logistic regression controlling for age, gender, and clinical
stage and considering ART adherence as a dichotomous
outcome (Complete/Incomplete). Crude and adjusted
prevalence ratios (PR) with their corresponding 95% con-
fidence intervals (CI 95%) were calculated to evaluate the
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Valenzuela‑Oréetal. BMC Public Health (2023) 23:497
magnitude of found associations. A backward stepwise
selection was performed, considering a significant level
of 0.2 for inclusion in the multivariate model.
Statistical analyses were performed using R 4.0.5, R
Foundation for Statistical Computing, Vienna, Austria.
A p-value less than 0.05 was considered statistically
significant.
Results
General characteristics
e study collected information from 208 participants
from 55 indigenous Awajun or Wampis communities
and 31 primary health care centers. e median age was
25 (22–32) years old, with 57.2% males and 88.9% from
Awajun population. Most of them were single (43.3%)
or reported living with a partner without being married
(45.2%), with a median income of US$ 73.7 (24.6-122.8),
although 47.6% reported not having any income. 174 par-
ticipants were living in a family (83.7%), although 21 par-
ticipants reported living alone and far away from family,
and 13 (6.2%) alone but close to family. 52.4% mentioned
that they did not usually travel to cities.
Most of the participants mentioned that they were
not included in a risk population (80.3%), but 16.8%
reported being included in the group of “men who
have sex with men” (MSM). ere was an approximate
median disease time of 3.6 years, with 24% of partici-
pants who reported having at least one opportunistic
condition at some point. Four cases of tuberculosis-HIV
co-infection were found.
73.1% of participants mentioned that they were using
only ART medications, but 18.8% reported using ART
concomitant with medicinal plants. e first-line thera-
peutic scheme was the most used (39.9%) with a median
treatment time of 2.8 years. 33.2% of respondents
reported having adverse effects during the ART.
When they were asked about their conceptualization
of the disease, the majority (82.7%) referred to a cause
consistent with current knowledge about this disease
(sexual transmission or blood transfusion); however, 13%
of participants referred to concepts of the disease related
to magical-religious origins. Most of the participants
(51.0%) reported receiving poor family support, and
26.9% perceived very poor family support. Additionally,
84.1% reported perceiving stigmatization in their health
facility due to their condition and 86.1% mentioned hav-
ing been discriminated against by being denied care in
health services due to their illness.
Most of the participants reported having state insur-
ance provided by the Ministry of Health - Seguro Inte-
gral de Salud (90.9%), but 4.8% mentioned not having any
health insurance. Additionally, the median time to travel
to the primary care center was 10 (5–30) minutes with
a maximum of five days approximately. 41.3% of partici-
pants reported any type of expense for traveling to the
health center, and 30.8% mentioned making any expense
to buy HIV treatment. Additional information about the
characteristics of participants is explained in Table1.
A complete ART adherence was evidenced in 28.8%
of participants (42.3% in Awajun people and 25% in
Wampis). e dimensions with better accomplishment
were taking medication at the indicated hour (76.0%) and
not stopping to take medication if they felt sick (74.5%).
In contrast, the dimension with the least accomplishment
was forgetting to take medication (53.8%). e results by
SMAQ dimensions are expanded in Table2.
Bivariate analysis
A significant statistical association was found between
ART adherence and marital status (p = 0.011), alcohol-
ism (p < 0.001), adverse reactions to ART (p < 0.001),
and reporting stigma (p = 0.021) or discrimination
(p = 0.003). e complete results of the bivariate analysis
are shown in Table3.
Multivariate analysis
When the multivariable analysis was performed, it was
observed that the interactions of age with the possible
associated factors did not have statistically significant
results, so it was decided to remove this variable as an
adjustment variable, however, age was retained in the
multivariate model.
Finally, it was observed that having an occupation was
associated with a greater probability of having complete
adherence (aPR 1.86; CI 95% 1.15–3.02), while having
any monthly income (aPR 0.64; CI 95% 0.41–0.99) and
reporting adverse effects (aPR 0.36; CI 95% 0.18–0.70)
were related to a lower probability of having complete
adherence. Although a significant effect of clinical stage
was evidenced, it was quite small and with wide confi-
dence intervals due to the small sample size in the study
categories. Complete results of crude and adjusted mod-
els are shown in Table4.
Discussion
is research found that 28.8% of surveyed people had
complete adherence to ART. In urban contexts in Peru,
previous research has found ART adherence levels of
65.1%, which is greater than the values found in this
study [16]. Similarly, Omosanya etal., (2013) found an
ART adherence of 88% in people living with HIV from a
rural tertiary medical center in Nigeria, which suggests
that area of residency is not necessarily a influencing fac-
tor on increasing adherence [18]. In contrast, Chavarry-
Ysla et al., (2020) found an ART adherence of 33% in
people from the Peruvian ethnic group Kusu-Pagata,
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Valenzuela‑Oréetal. BMC Public Health (2023) 23:497
Table 1 General characteristics of indigenous people living with
HIV from Condorcanqui and Bagua provinces ‑ Amazonas Region
Characteristics n (%)
Age (years-old)a25 (22–32)
Gender
Female 89 (42.8)
Male 119 (57.2)
Districtc
1 76 (36.5)
2 74 (35.6)
3 38 (18.3)
4 20 (9.6)
Ethnic group
Awajun 185 (88.9)
Wampis 20 (9.6)
Others 3 (1.4)
Marital status
Married 10 (4.8)
Single 90 (43.3)
With partner (non‑married) 94 (45.2)
Divorced 6 (2.9)
Widower 8 (3.4)
Educational level
Without studies 10 (4.8)
Primary level 44 (21.2)
Secondary level 130 (62.5)
Superior studies 24 (11.5)
Occupational status
Other jobs 91 (43.8)
Agriculture 60 (28.8)
Employed 26 (12.5)
Student 20 (9.6)
Laborer 10 (4.8)
Hunting or fishing 1 (0.5)
Religion
Evangelic 86 (41.3)
Non‑religious 38 (18.3)
Christian 34 (16.3)
Catholic 22 (10.6)
Israelite religión 6 (2.9)
Other 22 (10.6)
Income (S/.)a300 (100–500)
Yes 109 (52.4)
Not 99 (47.6)
Alcohol useb
Yes 47 (22.6)
Not 161 (77.4)
Tobacco useb
Yes 16 (7.7)
Not 192 (92.3)
Drug or illicit substance useb
Yes 3 (1.4)
Not 205 (98.6)
People who are living with
With family 174 (83.7)
Table 1 (continued)
Characteristics n (%)
Alone and far to the family 21 (10.1)
Alone but close to the family 13 (6.2)
Travelling frequently to the cities?
Yes 99 (47.6)
Not 109 (52.4)
Risk group
MSM 35 (16.8)
TG 4 (1.9)
TS 2 (1.0)
PG 167 (80.3)
Disease time (days) 1324.5
(417.8–1890.0)
Opportunistic diseases
Yes 50 (24.0)
Not 158 (76.0)
Clinical stage (CS)
CS1 196 (94.2)
CS2 9 (4.3)
CS3 3 (1.4)
CS4 0 (0.0)
TB-HIV coinfection
Yes 4 (1.9)
Not 204 (98.1)
Type of treatment
Only ART 152 (73.1)
Only with medicinal plants 9 (4.3)
ART and medicinal plants 39 (18.8)
Self‑medication 8 (3.8)
Therapeutic scheme
First line 83 (39.9)
Tenofovir based 78 (37.5)
Abacavir based 0 (0.0)
Zidovudine based 3 (1.4)
Does not know/ Not answer 44 (21.2)
Therapeutic time (days) 1028
(361–1687)
Adverse events to ART
Yes 69 (33.2)
Not 139 (66.8)
Health insurance
Not have 10 (4.8)
SIS 189 (90.9)
EsSalud 9 (4.3)
Transportation expendituresa
Not 122 (58.7)
Yes 86 (41.3)
Treatment expenditures
Not 144 (69.2)
Yes 64 (30.8)
MSM Men who have sex with men, TG Transgender people, SW Sexual workers,
GP General population, TB Tuberculosis, HvB Hepatitis B virus
a Results in median (interquartile range). bUse once per week at least. cThe name
of districts has not to be shown in order to keep condentiality of participants
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Valenzuela‑Oréetal. BMC Public Health (2023) 23:497
which is similar to this study [19]. is is consistent with
other studies in Latin American indigenous communities
with adults living with HIV, which report adherence lev-
els between 20–50%. [20].
No association was found between ART adherence and
personal characteristics. However, the profile is consist-
ent with previous research in indigenous people living
with HIV, with the exception of the gender distribution.
A previous publication about indigenous people from
Bolivia living with HIV reports a 5:3 ratio between males
and women [21], but findings from another publication
that reports the situation in eight Amazonian ethnic
groups in Brazil shows a distribution of 60% of women
affected by HIV infection [22].
An association between having an occupation and
the probability of having complete ART adherence was
found. More than 80% of surveyed people reported liv-
ing with their families and approximately 40% reported
having occasional jobs. ese social factors are closely
related to poverty conditions in the Condorcanqui prov-
ince, which is considered among the top 10 poorest
provinces in the country according to the INEI’s 2018
Monetary Poverty Map [23]. e occupational status has
Table 2 Adherence to ART in indigenous people from
Condorcanqui and Bagua‑Amazonas
Items N %
Do you ever forget to take your medication?
Yes 112 53.8
Not 96 46.2
Did you always take your medications at the right time?
Yes 158 76.0
Not 50 24.0
Do you ever stop taking your medicine if you feel sick?
Yes 53 25.5
Not 155 74.5
Did you forget to take your medication over the weekend?
Yes 69 33.2
Not 139 66.8
I have not taken more than two doses in the last week
None 118 56.7
1–2 46 22.1
3–5 9 4.3
6–10 2 1.0
More than 10 33 15.9
Did you forget to take the medicine more than two days, in the
last three months?
None 132 63.5
Less than two days 18 8.7
Two or more days 44 21.2
Not known /not answered 14 6.7
Table 3 Bivariate analysis of associated factors to ART adherence
in indigenous population from Condorcanqui and Bagua
provinces‑Amazonas
Characteristics Adherence p-valueb
Complete Incomplete
(n = 60) (n = 148)
Age (years old) 26 (22–32) 25 (22–32) 0.659a
Gender
Male 88 (73.9) 31 (26.1) 0.354
Female 60 (67.4) 29 (32.6)
Marital status
Married 3 (30.0) 7 (70.0)
Single 20 (22.2) 70 (77.8)
With partner (non married) 37 (39.4) 57 (60.6) 0.011
Divorced 0 (0.0) 6 (100.0)
Widower 0 (0.0) 8 (100.0)
With occupation
Not 22 (24.2) 69 (75.8) 0.218
Yes 38 (32.5) 79 (67.5)
With any regular income
Not 35 (35.4) 64 (64.6) 0.065
Yes 25 (22.9) 84 (77.1)
Alcohol use
Not 56 (34.8) 105 (65.2) < 0.001
Yes 4 (8.5) 43 (91.5)
Tobacco use
Not 58 (30.2) 134 (69.8) 0.161
Yes 2 (12.5) 14 (87.5)
Drug or illicit substance use
Not 60 (29.3) 145 (70.7) 0.558
Yes 0 (0.0) 3 (100.0)
Disease time (days) 1389.5 (383.8‑
1883.0)
1297.0 (443.2‑
1929.8)
0.953a
Opportunistic diseases
Not 51 (32,3) 107 (67,7) 0,072
Yes 9 (18,0) 41 (82,0)
Clinical stage
CS1 57 (29,1) 139 (70,9) 1,000
CS2 2 (22,2) 7 (77,8)
CS3 1 (33,3) 2 (66,7)
Adverse events related to ART
Not 53 (38,1) 86 (61,9) < 0,001
Yes 7 (10,1) 62 (89,9)
Disease conceptualization
Conventional 50 (29.1) 122 (70.9) 1.000
Magical or religious 10 (27.8) 26 (72.2)
Stigma
Not 4 (12.1) 29 (87.9) 0.021
Yes 56 (32.0) 119 (68.0)
Discrimination
Not 2 (6.9) 27 (93.1) 0.003
Yes 58 (32.4) 121 (67.6)
a U Mann‑Whitney Test
b Exact Fisher Test
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Valenzuela‑Oréetal. BMC Public Health (2023) 23:497
been proved to be a crucial element in improving ART
adherence in people, regardless of the income classifi-
cation of the countries they are from [24, 25]. Previous
research has hypothesized that the occupational status
could be related to more careful behaviors related to
improving self-care, in order to continue with productive
activities that contribute to maintaining life quality and
health status [25, 26].
Table 4 Multivariate model of associated factors to ART adherence in indigenous population from Condorcanqui and Bagua
provinces‑Amazonas
a Controlled by gender and clinical stage with a backward stepwise selection, considering a signicance level of 0.2 to select variables
Characteristics Univariate Multivariatea
PR (CI 95%) p-value PR (CI 95%) p-value
Age (years-old) 1,01 (0,98 − 1,04) 0,564 1,00 (0,98 − 1,02) 0,981
Gender
Male Ref Ref
Female 1,25 (0,82 − 1,92) 0,304 1,36 (0,84 − 2,18) 0,207
Marital status
Without partner Ref Non included
With partner 2,00 (1,26 − 3,18) 0,003
With occupation
Not Ref Ref
Yes 1,34 (0,86 − 2,10) 0,198 1,86 (1,15 − 3,02) 0,012
Having any income (S/.)
Not Ref Ref
Yes 0,65 (0,42 − 1,00) 0,052 0,64 (0,41 − 0,99) 0,045
Alcohol use
Not Ref Ref
Yes 0,24 (0,09 − 0,64) 0,004 0,46 (0,18 − 1,13) 0,091
Tobacco use
Not Ref Non included
Yes 0,41 (0,11 − 1,54) 0,189
Drug or illicit substance use
Not Ref Non included
Yes 0,00 (0,00–0,00) < 0,001
Disease time (days) 1,00 (1,00–1,00) 0,790 Non included
Opportunistic diseases
Not Ref Non included
Yes 0,56 (0,30 − 1,05) 0,071
Adverse events to TAR
Not Ref Ref
Yes 0,27 (0,13 − 0,55) < 0,001 0,36 (0,18 − 0,70) 0,003
Disease conceptualization
Conventional Ref Non included
Magical or religious 0,96 (0,54 − 1,70) 0,877
Use of medicinal plants
Not Ref Ref
Yes 0,44 (0,21 − 0,91) 0,026 0,53 (0,27 − 1,01) 0,054
Stigma
Not Ref Non included
Yes 2,64 (1,03–6,80) 0,044
Discrimination
Not Ref Ref
Yes 4,70 (1,21 − 18,25) 0,025 3,52 (0,92 − 13,41) 0,065
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Valenzuela‑Oréetal. BMC Public Health (2023) 23:497
In contrast, factors such as having any monthly income
or reporting adverse effects were related to not having
complete adherence. is study found that, in people
who receive a salary, the median income was lower than
the basic salary in Peru. Although previous research has
found some differences when using indicators such as
the Gini coefficient to measure variables like “income
inequality” [27], or when individual income is measured
through ordinal scales with more than two categories
[28]. It should be noted that the result is not a robust
measure and the confidence intervals of prevalence ratios
were close to the unit. erefore, an extremely care-
ful interpretation is highly suggested and the possibility
of a non-measured confounding effect as a cause of the
results should not be dismissed.
On the other hand, previous evidence has suggested
that the presence of any adverse effect related to ART is
strongly related to a decrease in adherence. For example,
a systematic review developed by Al-Dakkak etal., (2013)
explains that specific adverse events such as fatigue, taste
disturbance, or nausea were significantly related to hav-
ing lesser adherence, in comparison to people who do not
have other types of adverse events [29]. In this research,
data about adverse events were collected in a general
way, without specifications, so it is suggested that future
research develops more detailed instruments in order to
improve the quality of data related to this variable.
Additionally, it is important to consider other factors
that influence the relationship between adverse effects
and adherence, such as the response to access to health
services when these effects occur. Local qualitative
reports suggest that indigenous people who had adverse
effects had a higher probability of abandoning the treat-
ment, due to lack of transportation to reach health
services, lack of medicines and the consequent out-of-
pocket expense to assume treatment of adverse effects,
and lack of health professionals in primary level estab-
lishments. is, added to personal factors such as the
nutritional status of patients and cultural factors such as
the belief that medicines “cause harm,“ generate mistrust
towards health services in these populations [30].
Is important to be highlight that approximately 13%
of participants referred to a disease conceptualization
related to magical or religious origins. Previous qualita-
tive research has found some references, particularly in
awajun groups, about the “disease” (HIV) as a conse-
quence of sorcery (“brujeria”) on some members of the
community [31]. In this context, it is important to clarify
that this sorcery or harm (translated in Spanish as “daño”)
is only one of the numerous terms related to the complex
universe of affection relationships in the awajun cosmo-
vision of disease [32]. For example, previous research
referred to local expressions among Awajun people as “an
unprecedented proliferation of tunchis” (the first mytho-
logical shaman to live at the bottom of the waters), which
makes the evils or harm become something similar to the
symptoms of HIV-AIDS, as a result, they get sick and are
never saved [32]. is could explain some previous find-
ings related to not being afraid of being infected with
HIV by sexual transmission, favoring its spread and pos-
sibly limiting adherence to treatmentf [19].
Likewise, people reported that 18.8% combine ART
with medicinal plants, and 4.4% take only medicinal
plants as a treatment for their disease. Although the con-
sumption of medicinal plants is a common behavior in
chronic patients, especially in people living with HIV
[11, 19], among indigenous people, this could be consid-
ered as a ritual intervention with the use of specific types
of plants (“plantas aliadas”) and mobilization of cosmo-
logical ambits, which permit the restoration of physical
folds and soul (“dietar”) [32].
No association between the other sociocultural fac-
tors and ART adherence was found; however, more than
70% of surveyed people referred to bad family support
and more than 80% referred to stigma and discrimina-
tion in healthcare services because of their disease. It is
well known that people with good family support have
more probabilities of having regularity in medical con-
trols and adherence to antiretroviral treatment [33, 34].
In contrast, qualitative reports referred that many young
Awajun people living with HIV were thrown out of their
houses or have relatives who speak ill of them, which
favors the isolation of affected people [30].
Absence of family members or a partner could be a
factor that decreases resilience to adverse situations,
such as a HIV infection [35]. On the other hand, stigma
and discrimination can be structural and manifested in
institutionalized or social practices, both undermine
availability, access, or use of health services, and pre-
vent people from having a safe and protective family
and community environment [36]. ere is evidence
that people living with HIV and indigenous people,
independently, are victims of stigma and discrimina-
tion in healthcare services [31, 37], but only journalistic
reports suggested that these factors could be determi-
nants of leaving therapy or even hiding their diagnosis
until days before death [30]. Future studies, especially
with mixed methods approach, could be useful in dem-
onstrating possible relationships, independently of this
study’s findings.
ere were no association between clinical features
and ART adherence, but is important to note that almost
20% of surveyed individuals were identified as mem-
bers of risk groups: men who have sex with men (MSM)
(16.8%) and transgender people (1.9%). ese findings
are consistent with previous studies that have reported
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 10
Valenzuela‑Oréetal. BMC Public Health (2023) 23:497
a high risk of sexually transmitted diseases or HIV in
indigenous MSM [38]. Additionally, Bartlett etal. (2008)
reported in previous research on four communities from
the same region as the present study that all indigenous
men who tested positive for HIV were from the MSM
risk group, which represents 20% of total individuals liv-
ing with HIV [39].
One limitation of this study is the inability to carry out
a differentiated analysis by ethnicity, due to the small
sample size of Wampis people and “others,“ who typically
define themselves as “descendants of the union between a
Wampis person and an Awajun person.“ Future research
should better define this population group that continues
to identify as part of an “indigenous or native population”
despite being the product of the union between mem-
bers of different communities and analyze their health
problems.
Other limitations include the fact that the question-
naire did not include other components related to the
opinions or attitudes of indigenous people about ART
treatment, regardless of their adherence to it. Laura etal.
(2021) found that there were some cases where ART
treatment boxes were returned to health professionals
so that they could give them to others who needed them
more [30].
It is important to note that the methodological design
of the research does not allow for the establishment of
causal relationships, so future research should evaluate
the true magnitude of the associations found. Addition-
ally, the sample was obtained through a non-probabil-
istic method, so the results cannot be generalized to all
of Peru.
e most significant strength of this research is its
collaborative nature between researchers, regional
health managers, and participating communities, from
planning to execution. is allows for the short-term
implementation of improvements in the ART pro-
gram in these populations and emphasizes the impor-
tance of maintaining a constant intercultural dialogue
between indigenous communities and decision-makers
to quickly detect difficulties that may affect adherence
to treatment.
Conclusion
Only a third of participants reported complete adherence
to antiretroviral therapy. Factors associated with adherence
to antiretroviral medication were related to occupational
status and reporting adverse reactions to the therapeutic
scheme. Interventions aimed at improving adherence in
indigenous people living with HIV should take these fac-
tors into consideration in order to develop effective imple-
mentation strategies.
Abbreviations
ART Antiretroviral treatment
HIV Human immunodeficiency virus
INEI Instituto Nacional de Estadística e Informática – Perú
SMAQ Simplified Medication Adherence Questionnaire
WHO World Health Organization
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12889‑ 023‑ 15362‑y.
Additional le1.
Acknowledgements
Special thanks to the local authorities of the participating communities in the
provinces of Condorcanqui and Bagua; also, a special mention to the Provin‑
cial Municipality of Condorcanqui.
Authors’ contributions
Conceptualization: FV, YA, LL; methodology: FV, YA, LL; Research: FV, YA, LL, NC,
CC; formal analysis: FV, YA, LL; Writing ‑ Preparing the original draft: FV, YA, LL;
Redaction: review and editing: FV, YA, LL, NC, CC; Project Management: FV, YA,
LL. All authors reviewed the manuscript.
Funding
Instituto Nacional de Salud‑Lima, Perú.
Availability of data and materials
The data that support the findings of this study are available from Instituto
Nacional de Salud (Peru) but restrictions apply to the availability of these data,
which were used under license for the current study, and so are not publicly
available. Data are however available from the authors upon reasonable
request to Félix Valenzuela Oré (fvalenzuelao_12@yahoo.es) and with permis‑
sion of Instituto Nacional de Salud (Peru).
Declarations
Ethics approval and consent to participate
This research was conducted in accordance of national and international
guidelines (Declaration of Helsinski) and the protocol (OC‑036‑19) was
approved by the Institutional Research Ethical Committee (CIEI‑INS) and
Research and Technological Transference General Office (OGITT ) from Instituto
Nacional de Salud (Peru) with Directorial Resolution N°065‑2020‑OGITT/
INS. The informed consent for participation is obtained from all the study
participants.
Consent for publication
Not applicable.
Competing interests
The authors declare that they do not have any competing interest.
Author details
1 Centro Nacional de Salud Intercultural, Instituto Nacional de Salud Lima, Perú.
2 Dirección Regional de Salud Amazonas, Chachapoyas, Perú.
Received: 25 November 2022 Accepted: 2 March 2023
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