The core constructs and intrinsic relationships of ecosocial theory provide a means to better understand structural factors that influence HIV antiretroviral adherence, including criminalization of HIV exposure/transmission. Embodiment is a multilevel phenomenon that integrates soma, psyche, and society, within historical and ecological context  occurring through genealogical relationships that provides a clue to life histories, both hidden and revealed . Genealogical relationships also shape pathways to embodiment in the ecosocial environment that involve “exposure, susceptibility, and resistance (as both social and biological phenomena), structured simultaneously by societal arrangements of power… and constraint’s and possibilities of our biology” , p. 225. Internal and economical, and external and ecological intrinsic relationships shape accountability and agency (who and what is responsible for social inequities in health and for rectifying them)  among members of society. From an ecosocial theory perspective, it is important to consider the influence of HIV criminal laws and social capital on HIV antiretroviral adherence from multiple levels (e.g., individual, neighborhood, political jurisdiction, national) and in multiple domains (e.g., home, work, other public settings). This study’s participants represent many of the most vulnerable members of North American society.
HIV antiretroviral therapy adherence
Our analysis of the ecosocial factors influencing HIV ART adherence in North America identified significant positive associations between perceived social capital, HIV disclosure required by law, and self-reported HIV ART adherence. However, it is worth noting that there is no gold standard of HIV ART adherence measurement. All measures of HIV ART adherence have limitations [71, 74, 81, 82]. Medication event monitoring system (MEMS) use is difficult to implement because of high cost and patient resistance/lack of cooperation and difficulty to monitor MEMS devices and data retrieval when study visits are as long as 6 months apart. Pill counts, pharmacy refill data, and therapeutic plasma drug monitoring all have drawbacks that limit their utility. Considering these factors and the inter-correlations among these measurement approaches [82, 83], we used two well-validated adherence measures. The visual analog scale (VAS) developed by Walsh [71, 84] that assesses 30-day adherence reporting septely for each drug along a continuum anchored by “none of my doses” to “every one of my doses.” This measure has shown to be correlated with other measures of adherence, such as MEMS [71, 85] and a 30-day timeframe has recently been supported as preferable to other approaches of self-report . We also used a 30-day adherence rating scale that has been recommended by Lu and colleagues , in which participants are asked “Thinking back over the past 30 days, rate your ability to take all your medications as prescribed” (6 response ratings: Very poor, Poor, Fair, Good, Very good, and Excellent). This approach has yielded the least over-reporting when compared to MEMS. These approaches, however, are still susceptible to reporting biases and likely suggest an overestimate of actual adherence. Conservatively, we chose to dichotomize at perfect vs. less than perfect adherence; finer gradations in the self-reported adherence data (e.g., 90%, 80%) are questionable given the nature of the instrument and the imprecision of recall and reporting of medication-taking behavior.
Our statistical analyses were only sensitive to the most stringent rates of HIV ART adherence (i.e. 100% adherence). This finding leads us to believe that longitudinal research that explore our model constructs is needed to more fully understand how HIV-related criminal prosecutions and perceived social capital influence HIV ART adherence among persons living with HIV in North America. Future studies should include both longitudinal and multi-site study designs that specifically inquire about PLWH’s encounters with the criminal justice system in addition to measuring their perceptions of social capital and HIV ART adherence. In addition to quantitative studies, there needs to be qualitative research that explores at the individual level the influence that HIV-related criminal law approaches have on the lives of PLWHs and how they navigate their experiences with stigma and discrimination that these laws perpetuate.
Many factors that influence a person’s HIV antiretroviral adherence have been documented, including individual factors (e.g., anxiety, depression, illicit drug use, knowledge about disease and medication regimen), interpersonal factors (e.g., social support, effective patient-provider relationships), and social/structural factors (e.g., homelessness, access to care and treatment). Among our study’s participants, evidence of the influence of anxiety and depression on HIV antiretroviral adherence has been documented . Support for adherence self-efficacy predicted adherence behavior, among our participants and may partially mediate environmental influences and cognitive or personal factors . Additionally, factors that mediate HIV antiretroviral adherence among participants include sense of coherence (“overall well-being and ability to cope with stress” ), self-compassion, and engagement in care . The information from these studies highlights the effects of individual and interpersonal level factors that influence adherence among our participants and suggest that additional structural factors may also influence adherence. The criminalization of HIV exposure/transmission may not be the only structural level factor that influences adherence among our study participants. Homelessness and access to care and treatment may also influence adherence among our study’s participants, however we do not have data to support these conclusions.
Criminalization of HIV exposure/transmission and HIV-related prosecutions
HIV antiretroviral adherence is an essential component of managing HIV at both individual and population levels. Our study’s use of ecosocial theory, allows us to better understand the internal and economical and external and ecological intrinsic relationships and the cumulative interplay among exposure, susceptibility, and resistance that influence HIV antiretroviral adherence as part of the embodied social ecology for our study’s participants. Our findings related to adherence among PLWH who live in jurisdictions were the potential for HIV-related prosecutions exist underscore the complex social dynamics at play in the discourse about the use of criminal law to manage HIV disease. The challenge of balancing individual rights to freedom of sexual expression and the protection of the health of a population are at odds here. Criminalization of HIV exposure/transmission as a prevention intervention has limited efficacy [9–11, 14, 17] and does not provide sufficient protection for persons who engage in high risk sexual behavior, who may assume they are protected because there is a law to protect them. The continued practice of prosecuting persons for HIV-related “crimes” may actually limit the effectiveness of other HIV prevention interventions. There is also evidence that continued HIV-related prosecutions may reduce the likelihood that persons who know their HIV status will seek treatment . Human rights based HIV prevention interventions may allow us to capitalize on altruistic behaviors exhibited by PLWH [14, 17].
The teleological intrinsic relationship described by Krieger  and our findings of associations between the legal context of HIV and ART adherence may be evidence of the existence of the concept of “therapeutic citizenship” in North America. This concept has been used to characterize rates of adherence to ART among PLWH in developing nations . The concept is based on the view that citizenship is “enacted through a web of institutional and political cultures, rather than the more classic understanding of the political relationship between citizen and state”  p. 34. Nguyen et al.  used the concept of therapeutic citizenship to understand exemplary adherence observed in societies whose governments have severely limited economic resources for the provision of health care and social services. In these societies, PLWH are challenged with retaining familial and social networks while navigating and accessing health care and social service resources from governmental agencies. They described environments where PLWH appropriate ART as a set of rights and responsibilities that facilitate their negotiation of conflicting moral economies in their fight to manage HIV and remain viable members of society .
We contend that the concept of therapeutic citizenship among PLWH is applicable in Canada and the United States because the potential for prosecution for HIV nondisclosure, exposure, or transmission creates conflict between the individual and society. Our findings of higher rates of adherence in geographic locations where prosecutions for HIV occur may be partially explained by a desire among PLWH to be “good therapeutic citizens” and protect others from exposure to HIV . An alternate explanation for this finding may be that PLWH fear being accused of not being a good therapeutic citizen and facing the potential for HIV-related prosecution . Through the practice of adherence to HIV antiretroviral medications, PLWH reduce the likelihood of exposing others to HIV. We suspect that our observation of increased adherence to HIV ART in jurisdictions where HIV disclosure is a legal requirement is partially explained by “therapeutic citizenship” being enacted by our participants and an example of their ethical commitment to protect others from exposure to HIV .
From a public health perspective, it is disconcerting that HIV-related prosecutions and the criminalization of HIV exposure/transmission continues. HIV is currently the only disease for which people can be prosecuted even if they do not transmit the virus to another person. The criminalization of HIV exposure/transmission as a structural HIV prevention intervention may create a “catch 22” scenario for PLWH. PLWH who work to achieve optimal health and engage in practices to be a good therapeutic citizen by adhering to HIV ART may lose hope for living a normal life in a society that does not accept them as human beings. The continued practice of HIV-related prosecutions and criminalization of HIV exposure/transmission contributes to the creation of a viral underclass  that faces stigma and discrimination with the threat of prosecution and incarceration .
Perceived social capital
The intrinsic relationships within ecosocial theory most relevant to understanding perceived social capital in our study are internal and economical and external and ecological relationships. Our findings related to perceived social capital highlight the importance of social networks and the collective ability of PLWH to navigate the challenges they face in their daily lives. Perhaps this is because our study participants hold similar socioeconomic position within their respective geographic locations. This leads us to believe that the importance of social capital and the “credits” it offers individual members of a society may be essential elements in the global fight to end the HIV epidemic. In addition, our findings related to perceived social capital reinforce the importance of the concept of therapeutic citizenship as a collective benefit to PLWH and all members of societies where they live.
Our study was influenced by an overrepresentation of factors that are relevant to contexts within the United States because of the large number of surveys collected within the United States. This limitation reduces the ability to generalize findings outside the United States, because there may be insufficient power to determine statistical differences for our Canadian site. The non-random recruitment strategy used may introduce bias, which may be especially evident in the level of perceived social capital, because persons participating may have sufficient social capital to gain access to the health care resources they need, including participation in research studies. Our reliance on ART adherence self-report survey data and lack of biological markers to assess adherence may have resulted in biased data. In the absence of an affordable and non-invasive adherence measure , we believe that reliance on the 30-day self-report visual analogue scale used provided valid and sufficient ART adherence information to determine the effects of structural factors influencing ART adherence. Additionally, our study’s survey responses may be influenced by social desirability bias.
Additional limitations indicative of the complexity of studying structural challenges influencing HIV include the challenge of obtaining accurate and current legal and policy information related to the criminalization of HIV and how ancestry (race/ethnic) data were collected. Our use of the United States’ Census Bureau ancestry (race/ethnic) categories complicates interpretation of data from our Canadian study site . Use of this classification system may be insufficient to accurately represent epidemic trends in Canada and the United States. Our study findings provide limited evidence about the effects of HIV-related criminal laws and social capital on HIV ART adherence among women, transgender, and other minority groups. Thereby limiting our ability to understand the effect of HIV-related criminal laws on the HIV ART adherence behaviors of women, transgender, and other minority members of society.