title: Effect of social relationships on antiretroviral medication adherence for people living with HIV and substance use disorders and transitioning from prison.
abstract: BACKGROUND
  This paper examines how family and social relations facilitate and inhibit adherence to antiretroviraltherapy (ART) for people living with HIV (PLH) who have underlying substance use disorders and are transitioningto the community post-incarceration.
  
  
  METHODS
  Combining the methods of inductive close reading and constantcomparison, we analyzed the data from 30 semi-structured interviews of PLH who had recently transitioned to thecommunity within the previous 90 days.
  
  
  RESULTS
  Three central themes were anticipated as important socialrelationships post-release: self-reported family, friends and clinicians. Among these, four sub-themes (social isolation, 'double jeopardy', search for belonging, and trust and respect) emerged, highlighting how they impacted ART adherence. Post-release, participants returned to resource-poor communities where they experienced socialisolation. ART adherence was enabled by having a purpose in life, which correlated with having robust family support structures. Many former prisoners felt that a chasm between them and their families existed, both because of HIV stigma and their addiction problems. In this context, relationships with untrustworthy friends from their druguse networks led to relapse of drug use and risky behaviors, jeopardizing participants' ART adherence and persistence. To avoid the double jeopardy, defined as seeking friends for support but who were also the ones who contributed to drug relapse, participants searched for new social anchors, which often included their healthcare providers who represented trusted and respected persons in their life.
  
  
  CONCLUSIONS
  While some former prisonersperceived doctors as uncaring and their relationships asymmetrical, positive relationships with these providers,when respect and trust was mutual, reinforced the participants' sense of belonging to what they called 'the world that don't do drugs' and motivated them to adhere to ART.
authors.affiliation: Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-2283 USA.
authors.forename: Julia
authors.initials: J
authors.lastname: Rozanova
authors.affiliation: Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-2283 USA.
authors.forename: Shan-Estelle
authors.initials: SE
authors.lastname: Brown
authors.affiliation: Harvard Medical School, Boston, MA USA.
authors.forename: Ambika
authors.initials: A
authors.lastname: Bhushan
authors.affiliation: Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-2283 USA.
authors.forename: Ruthanne
authors.initials: R
authors.lastname: Marcus
authors.affiliation: Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-2283 USA ; Division of Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, CT USA.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
keywords: Addiction; Adherence; Antiretroviral therapy; Clinicians; Family; Friends; People living with HIV; Prisoners; Qualitative interviews; Social relationships; Trust in Physician