Method

Results

Figure 1 shows the study selection strategy flowchart according to the PRISMA protocol (^{Galvão et al., 2015}) and Table 1 explains the main characteristics of the studies included in the final sample. As presented in Table 1, 14 articles were retrieved.

Figure 1: Flowchart corresponding to selection of the studies, according to PRISMA 

In relation to the participants, three papers were carried out with men who have sex with men (MSM); of these, two studies were conducted with the black-skinned population (^{Tan et al., 2018}; ^{Graham et al., 2018}) and one with MSM at an American health center for Latinos near the border with Mexico (^{Sauceda et al., 2016}). Three articles were conducted with women (^{Dale et al., 2014}; ^{Fletcher et al., 2020}; ^{Kerkerian et al., 2018}). Two studies researched users of public health centers with limited resources in the African continent (^{Musiimenta et al., 2018}; ^{Nanfuka et al., 2018}). One paper dealt with low-income black-skinned and Latino populations (^{Jaiswal et al., 2020}). One study was conducted with refugees (^{Mendelsohn et al., 2014}). One survey interviewed adolescents and young adults with HIV (^{Chenneville et al., 2018}), whereas ^{Chongo et al. (2020}) researched native Canadian men. ^{Wen et al. (2020}) interviewed users of health services in a Chinese city and ^{Seidl and Remor (2020}) approached people undergoing medical and psychosocial follow-up in a Brazilian hospital.

Table 1: General characteristics of the studies 

Also, according to Table 1, it is verified that six quantitative studies, seven qualitative ones and one mixed-methods paper were retrieved. The corpus categorization is presented below, in three main topics:

2) Approach to resilience

The articles analyzed dealt with resilience using different conceptual approaches. These approaches, as well as the instruments employed to assess resilience, are summarized in Table 2 T3.

Table 2: Definition and instruments used in the approach to resilience 

^{Mendelsohn et al. (2014}), ^{Chenneville et al. (2018}), ^{Tan et al. (2018}), ^{Graham et al. (2018}), ^{Jaiswal et al. (2020}), ^{Chongo et al. (2020}) and ^{Fletcher et al. (2020}) approached resilience as a process. It is noted that, in their paper, ^{Chenneville et al. (2018)} include resilience processes, in which it can be approached as biological, behavioral, social and community-based. Five research studies defined resilience as a characteristic of the person that allows them to deal with adversities (^{Dale et al., 2014}; ^{Kerkerian et al., 2018}; ^{Sauceda et al., 2016}; ^{Seidl & Remor, 2020}; ^{Wen et al., 2020}). In turn, ^{Nanfuka et al. (2018}) and ^{Musiimenta et al. (2018}) approached resilience as the ability of PLHIV to overcome adversities and sustain adherence to the treatment; in these two studies and in the one by ^{Chenneville et al. (2018)}, adherence to antiretrovirals was and indicator of resilience.

In relation to the instruments employed in the approach to resilience (Table 2), seven studies resorted to interviews (^{Chongo et al., 2020}; ^{Graham et al., 2018}; ^{Jaiswal et al., 2020}; ^{Mendelsohn et al., 2014}; ^{Musiimenta et al., 2018}; ^{Nanfuka et al., 2018}; ^{Tan et al., 2018}). In addition to the interviews, ^{Chongo et al. (2020)} used focus groups, and ^{Nanfuka et al. (2018)} employed conversations and observation of the participants. Among the studies that employed validated instruments, ^{Dale et al. (2014}), ^{Sauceda et al. (2016}), ^{Seidl and Remor (2020}) and ^{Wen et al. (2020}) used the Connor Davidson Resilience Scale (CD-RISC), ^{Kerkerian et al. (2018}), the Resilience Scale (RS10) and ^{Fletcher et al. (2020}) resorted to the Brief Resilience Scale. In turn, ^{Chenneville et al. (2018}) used viral load as a parameter for biological resilience and adherence to ART for behavioral resilience.

Discussion

This integrative literature review explored the role of resilience in adherence to ART among PLHIV. The analysis of a decade of production in this field showed an increase in studies from 2018 onwards, and this trend may be related to the recent theoretical accumulation on the infection and the new prevention technologies that have emerged in recent years, especially those structured from ART use (^{Rodger et al., 2019}; ^{Sabapathy et al., 2022}).

TasP, the HIV care cascade and the Unaids targets led to an increase in the number of people undergoing treatment (^{Brito & Seidl, 2019}; ^{Seidl & Remor, 2020}), in addition to fostering monitoring and research of the HIV indicators from the global response to the pandemic and the vulnerability and protection factors for preventing and coping with HIV/AIDS. However, research studies on the topic are still incipient in the national and international literature (^{Araújo et al., 2019}; ^{Brito & Seidl, 2019}; ^{Dulin et al., 2018}; ^{Jimenez-Torres et al., 2017}). These authors point to the lack of literature on resilience in contexts of chronic diseases, mainly in relation to HIV/AIDS and associated with the impact of this construct on health care, physical health and progression of the disease.

There were variations in the groups of participants from the studies reviewed. Most of the studies were carried out with populations exposed to multiple vulnerabilities, such as social, ethnic, racial, gender inequalities and stigmatizing processes, in addition to the HIV experience itself. The literature highlights that there are differences in the way adherence to ART and resilience are presented cross PLHIV populations and contexts, remaining a challenge to sustain adherence in scenarios with different social and structural realities (^{Lacombe-Duncan et al., 2020}; ^{Mendelsohn et al., 2014}; ^{Nanfuka et al., 2018}). In general, the HIV infection disproportionately affects minority and economically disadvantaged groups, rendering it important to study resilience with these population segments, which need specific strategies for HIV prevention and interventions to cope with the disease (^{Chenneville et al., 2018}; ^{Kerkerian et al., 2018}).

According to ^{Unaids (2021)}, in 2020 there were 1.5 million new HIV infections predominantly among key populations, their companions and their sex partners, corresponding to 65 % of the infections. However, these population groups remain invisible and distant from health services for HIV, as can be corroborated in the current review.

The existing inequalities in access and adherence to the treatment are the result of excluding or nonexistent public policies and actions. Vulnerabilities support the social invisibility experience, which in turn is related to stigma, prejudice and discrimination, leading to intense psychosocial distress (^{Unaids, 2019}). Investigating the role of individual and community resilience in overcoming adverse health outcomes and social barriers, especially in people who face adversity and significant stressors, is a priority for global public health (^{Fletcher et al., 2020}; ^{Graham et al., 2018}; ^{Kerkerian et al., 2018}; ^{Nanfuka et al., 2018}; ^{Tan et al., 2018}).

In this review, it was possible to perceive variations in the adherence rates between population groups, even within the same country, such as the United States, where studies with PLHIV with low adherence were carried out (^{Jaiswal et al., 2020}) as well as surveys that found average and high adherence rates. ^{Dale et al. (2014}) assessed 76.5 % adherence in women living with HIV, whereas ^{Sauceda et al. (2016}) obtained 91.6 % adherence in their research conducted with Latino MSM. High adherence rates were also found in developing countries. ^{Mendelsohn et al. (2014}) verified between 90 % and 91 % adherence in refugees from Kenya and Malaysia. In addition to showing the heterogeneous character of the HIV/AIDS pandemic and, consequently, of adherence to antiretrovirals, which represents a major challenge for public health, this variability in the adherence rates points to the complexity of assessing adherence to ART, given that there is no gold standard measure for adherence, which can hinder comparing outcomes across studies (^{Carvalho et al., 2019}).

All the studies analyzed included a conceptualization of resilience, although from different approaches. In general, they highlighted that resilience allows people to overcome potentially traumatic circumstances and adapt positively to adverse conditions. Some studies approached resilience as a process whereas others did so as a characteristic of each person. For ^{Pruchno et al. (2015}) there is a continuous debate involving the nature of resilience, sometimes as a personality trait and other as a dynamic process. There are growing criticisms about defining resilience exclusively as an individual phenomenon, as this ignores the social context and systems in which resilience can occur. In the HIV/AIDS context, permeated by significant vulnerabilities, such approach might contribute to blaming PLHIV and increasing the stigma related to the illness, with the risk of losing sight of the multiple health determinants that permeate the existence of this population segment (^{Dulin et al., 2018}; ^{Harrison & Li, 2018}; ^{Unaids, 2019}).

In this scenario, ^{Dulin et al. (2018}) explore resilience as a resource that promotes positive psychological, behavioral and/or social adaptation in the face of stressors and adversity. Therefore, such resources would protect the health of PLHIV by promoting positive health behaviors and allowing them to deal positively with the adversities of living with HIV. Among the resilience resources, the literature herein retrieved refers to self-efficacy, the capacity for positive coping with adversity, positive religious coping, optimism, hope, self-compassion, resistance, compassionate love, self-esteem, control and problem-solving beliefs, good relationships with health professionals and services, and social support.

Some of the studies reviewed conceptualized resilience as the ability of PLHIV to sustain adherence to the treatment (^{Chenneville et al., 2018}; ^{Musiimenta et al., 2018}; ^{Nanfuka et al., 2018}). Among these papers, ^{Chenneville et al. (2018)} encompass resilience processes as biological, cognitive, behavioral, social and community-based. ^{Harper et al. (2014)} also used this definition and evidenced in their intervention with adolescent trans women and young adults living with HIV that resilience processes included cognitive processes that promote health, adoption of healthy behavioral practices and mobilization of social support. For ^{Hussen et al. (2017}), cognitive and behavioral resilience is associated with health-promoting psychosocial factors. Also in conceptual terms, the definition of the construct as involvement in health care also emerged (^{Jaiswal et al., 2020}; ^{Tan et al., 2018}), in a sense that would allow for the adaptation and management of elements associated with the therapeutic path.

Regarding the testing instruments, it is observed that general resilience scales were used that were not developed or adapted for the PLHIV condition. ^{Dulin et al. (2018}) point out the importance of resilience measures aimed at PLHIV that capture this construct not only at an individual level, but in its complexity and multiple levels. ^{Brito and Seidl (2019}) reported on the difficulty finding validated resilience instruments for PLHIV in Brazil, which evidences a significant gap in the field of research on resilience and HIV infection. The use of qualitative instruments, such as interviews, was referred to as appropriate in a complex context, allowing greater flexibility and depth (^{Jimenez-Torres et al., 2017}; ^{Pruchno et al., 2015}).

All papers analyzed recognize that resilience can modulate a person's ability to deal with the stressors of living with HIV and its health care, with 11 studies showing that resilience was associated with better adherence to ART or influenced engagement with treatment and adherence. When thinking about seropositivity, resilience allows PLHIV to overcome psychological, social and economic barriers to accepting their condition, preventing the impacts of the disease and developing their well-being and quality of life; however, it is reiterated that resilience should be understood as a complex and dynamic phenomenon built from the relationship between a person and their social context (^{Brito & Seidl, 2019}; ^{Jimenez-Torres et al., 2017}). The study by ^{Nanfuka et al. (2018}) showed that, even with several barriers, the participants maintained adherence to ART, making use of the resources from their social networks to continue the treatment, which reiterates the importance of social support networks in promoting resilience among PLHIV in environments with limited resources (^{Dulin et al., 2018}; ^{Nanfuka et al., 2018}; ^{Ungar et al., 2013}).

The research by ^{Sauceda et al. (2016}), conducted with Latin American MSM living with HIV, evidenced that people with a history of sexual abuse in childhood reported greater depressive symptoms and worse adherence, mainly when they were not able to deal with the stressful event but, as their resilience was strengthened, they managed to cope better with the traumatic situation and their adherence to antiretrovirals was increased. Resilience can be developed or reinforced and depends on social factors and environmental influences and on the resilience processes to occur when individuals encounter a stressful situation and have access to or have protective conditions that isolate them against the negative effects of that stress (^{Harper et al., 2014}). ^{Chongo et al. (2020}) warn that, although some studies postulate that resilience increases with exponential exposure to a traumatic experience, this assumption needs to be understood sparingly so as not to trivialize and romanticize the resilience process, considering that although trauma is always harmful and imposes distress, not everyone who experiences it develops a psychopathology and/or becomes more resilient.

Introducing the concept of resilience has contributed a new panorama to studies on HIV/AIDS: the analysis of protective factors, known to be associated with positive health outcomes (^{Brito & Seidl, 2019}; ^{Jimenez-Torres et al., 2017}). When thinking about strategies to strengthen resilience resources, it is important to consider the complexity of this phenomenon, the multiplicity of elements to which it is related and the different cultural contexts involved. Based on the synthesis of the diverse evidence available in the literature, it is recommended that the topic should be included more systematically in research and health care protocols, expanding the list of knowledge for future designs.

Final considerations

The literature review indicated that few studies evaluated the relationship between resilience and adherence, in addition to diversity of approaches to resilience and scarcity of validated instruments for this construct aimed at PLHIV, which presents itself as a significant gap in this theme. It is observed that the papers analyzed recognize that resilience can modulate a person's ability to deal with the stressors of living with HIV and its health care, highlighting the importance of resilience in this context and the need for evidence-based actions in health services to improve adherence to antiretrovirals, with a focus on building resilience. Thus, the role of resilience in this context is reinforced, as well as of strengthening adherence, which can lead to better health outcomes. It is noted that this synthesis was produced from a few studies retrieved from the current review, emphasizing the need for this topic to continue to be investigated, as well as the importance of future surveys that retrieve increasingly recent evidence and that add up to already consolidated knowledge in the area.

This review also signaled the importance of studying resilience and its social and population-based determinants. It is noted that research studies investigating the relationship between resilience, adherence to ART and clinical, emotional and social conditions, as well as interventions that address these dimensions, would contribute to the academic and technical areas, as well as to the general population. Among the limitations of the current study, it is noteworthy that the review did not consider retention in health services and clinical outcomes, such as the relationship between resilience with CD4 lymphocyte counts and HIV viral loads. Such delimitation is recommended for future studies. Although this study favored the integrative review strategy based on the concept of evidence-based practice, which only considered empirical articles, knowledge from other designs can be added, such as scoping reviews. Due to the fact that few studies have been retrieved, exploration of the phenomenon based on a scoping review, more exploratory, may allow access to diverse evidence built in different scenarios and that have not yet been published, for example, in sources captured by the databases/libraries employed in this review. Follow-up of this literature, perennially updating the available evidence, can contribute to the role of resilience in adherence to be increasingly matured. It is essential that there is an increase in the number of measuring instruments, which should be increasingly refined in order to compare a complex concept that has also been problematized in the health field.