Open Access Highly Accessed Open Badges Research article

Associations between the legal context of HIV, perceived social capital, and HIV antiretroviral adherence in North America

J Craig Phillips1*, Allison Webel2, Carol Dawson Rose3, Inge B Corless4, Kathleen M Sullivan5, Joachim Voss6, Dean Wantland7, Kathleen Nokes8, John Brion9, Wei-Ti Chen10, Scholastika Iipinge11, Lucille Sanzero Eller12, Lynda Tyer-Viola13, Marta Rivero-Méndez14, Patrice K Nicholas15, Mallory O Johnson16, Mary Maryland17, Jeanne Kemppainen18, Carmen J Portillo19, Puangtip Chaiphibalsarisdi20, Kenn M Kirksey21, Elizabeth Sefcik22, Paula Reid23, Yvette Cuca19, Emily Huang19 and William L Holzemer24

Author Affiliations

1 Faculty of Health Sciences, University of Ottawa School of Nursing, 451 chemin Smyth Road, Ottawa, ON K1H 8M5, Canada

2 Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44122, USA

3 Department of Community Health Systems, University of California School of Nursing, San Francisco, CA 94143-0608, USA

4 MGH Institute of Health Professions, CNY 36 1st Avenue, Boston, MA 02116, USA

5 University of Hawaii School of Nursing, McCarthy Mall, Webster 439, Honolulu, HI 96822, USA

6 University of Washington School of Nursing, Box 357266, Seattle, WA 98103, USA

7 Office of Research & Evaluation, Rutgers College of Nursing, Ackerson Hall, 180 University Avenue, Room 330, Newark, NJ 07102, USA

8 Hunter College, CUNY, Hunter Bellevue SON, 425 East 25 Street, Box 874, New York, NY 10010, USA

9 Duke University School of Nursing, 20 West Bridlewood Trail, Durham, NC 27713, USA

10 Yale University School of Nursing, PO Box 27399, West Haven, CT 06516-7399, USA

11 University of Namibia Main Campus, Mandume Ndemufayo Avenue, Block F, Room 204, 3rd Level, Windhoek, Namibia

12 Rutgers College of Nursing, 101 Glen Rock Road, Cedar Grove, NJ 07009, USA

13 MGH Institute of Health Professions, 3047 Bonnebridge Way, Houston, TX 77082, USA

14 University of Puerto Rico, PO Box 365067, San Juan, PR 00936-5067, Puerto Rico

15 Global Health and Academic Partnerships, Brigham and Women's Hospital and MGH, Institute of Health Professions, 36 1st Avenue, Boston, MA 02129, USA

16 University of California, 50 Beale Street, Suite 1300, San Francisco, CA 94105, USA

17 Chicago State University College of Health Sciences, Department of Nursing, 420 S. Home Avenue, Oak Park, IL 60302, USA

18 University of North Carolina Wilmington, 601 S. College Road, Wilmington, NC 28403, USA

19 University of California, School of Nurisng, 2 Koret Way, San Francisco, CA 94143, USA

20 Shinawatra University, School of Nursing, 99 Moo 10, Bangtoey, Pathumthani, Samkhok 12160, Thailand

21 Nursing Strategic Initiatives, Lyndon B. Johnson Hospital – Executive Administration, Harris Health System, 5656 Kelley Street, Houston, TX 77026, USA

22 Texas A&M University-Corpus Christi, 6300 Ocean Dr. Island Hall, Rm 329, Corpus Christi, TX 78404, USA

23 The University of North Carolina at Wilmington, School of Nursing, 601 College Road, Wilmington, NC 28403-5995, USA

24 Rutgers College of Nursing, Ackerson Hall, 180 University Avenue, Room 302C, Newark, NJ 07102, USA

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BMC Public Health 2013, 13:736  doi:10.1186/1471-2458-13-736

Published: 8 August 2013



Human rights approaches to manage HIV and efforts to decriminalize HIV exposure/transmission globally offer hope to persons living with HIV (PLWH). However, among vulnerable populations of PLWH, substantial human rights and structural challenges (disadvantage and injustice that results from everyday practices of a well-intentioned liberal society) must be addressed. These challenges span all ecosocial context levels and in North America (Canada and the United States) can include prosecution for HIV nondisclosure and HIV exposure/transmission. Our aims were to: 1) Determine if there were associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital (resources to support one’s life chances and overcome life’s challenges), and HIV antiretroviral therapy (ART) adherence among PLWH and 2) describe the nature of associations between the social structural factor of criminalization of HIV exposure/transmission, the individual factor of perceived social capital, and HIV ART adherence among PLWH.


We used ecosocial theory and social epidemiology to guide our study. HIV related criminal law data were obtained from published literature. Perceived social capital and HIV ART adherence data were collected from adult PLWH. Correlation and logistic regression were used to identify and characterize observed associations.


Among a sample of adult PLWH (n = 1873), significant positive associations were observed between perceived social capital, HIV disclosure required by law, and self-reported HIV ART adherence. We observed that PLWH who have higher levels of perceived social capital and who live in areas where HIV disclosure is required by law reported better average adherence. In contrast, PLWH who live in areas where HIV transmission/exposure is a crime reported lower 30-day medication adherence. Among our North American participants, being of older age, of White or Hispanic ancestry, and having higher perceived social capital, were significant predictors of better HIV ART adherence.


Treatment approaches offer clear advantages in controlling HIV and reducing HIV transmission at the population level. These advantages, however, will have limited benefit for adherence to treatments without also addressing the social and structural challenges that allow HIV to continue to spread among society’s most vulnerable populations.

Ecosocial theory; HIV/AIDS; HIV-related prosecution; Jurisprudence; Sexual minority; Vulnerable populations