HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES)

Abstract

The HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES) is a psychometric instrument developed by Johnson et al. (2007) to evaluate an individual’s cognitive appraisal of their capability to adhere to complex medical regimens and health-promoting behaviors within the context of living with Human Immunodeficiency Virus (HIV). Specifically conceptualized during the era of Highly Active Antiretroviral Therapy (HAART), the HIV-ASES operationalizes Albert Bandura’s social cognitive theory to assess self-efficacy expectations under conditions of adversity, interpersonal challenge, physical symptomatology, and daily routine disruptions. The instrument comprises 12 items rated on an 11-point visual analogue or numeric response format ranging from 0 (“cannot do at all”) to 10 (“completely certain can do”).

Psychometric evaluations have demonstrated a robust two-factor structure reflecting Integration (the behavioral capability to incorporate medical regimens, clinic visits, and health practices seamlessly into routine life and social domains) and Perseverance (the motivational persistence to continue therapy amidst acute side effects, emotional distress, physical illness, and discouragement). Internal consistency reliabilities for the overall scale consistently exceed α = .90, with subscale alphas typically spanning .85 to .92 across diverse socioeconomic, ethnic, and gender cohorts. The scale displays strong construct, convergent, criterion-related, and predictive validity, significantly predicting objective medication adherence indicators—such as electronic pill monitoring via Medication Event Monitoring Systems (MEMS)—as well as physiological biomarkers including viral suppression and CD4+ T-cell trajectories. The HIV-ASES stands as an essential measurement tool in behavioural medicine, translational clinical trials, and clinical neuropsychology.

Keywords

HIV Treatment Adherence Self-Efficacy Scale, HIV-ASES, antiretroviral therapy, HAART adherence, self-efficacy, Social Cognitive Theory, behavioral medicine, psychometrics, viral suppression, medication adherence

Authors

The HIV Treatment Adherence Self-Efficacy Scale was formulated and validated by a multidisciplinary team of behavioral scientists, clinical psychologists, and health disparities researchers affiliated with the Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco (UCSF), and the HIV Center for Clinical and Behavioral Studies at Columbia University and the New York State Psychiatric Institute:

• Mallory O. Johnson, Ph.D. – Department of Medicine, Center for AIDS Prevention Studies (CAPS), University of California, San Francisco (UCSF), San Francisco, California, USA.
• Torsten B. Neilands, Ph.D. – Department of Medicine, Center for AIDS Prevention Studies (CAPS), University of California, San Francisco (UCSF), San Francisco, California, USA.
• Samantha E. Dilworth, M.S. – Department of Medicine, Center for AIDS Prevention Studies (CAPS), University of California, San Francisco (UCSF), San Francisco, California, USA.
• Stephen F. Morin, Ph.D. – Department of Medicine, Center for AIDS Prevention Studies (CAPS), University of California, San Francisco (UCSF), San Francisco, California, USA.
• Robert H. Remien, Ph.D. – HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, New York, USA.
• Margaret A. Chesney, Ph.D. – Department of Medicine, Osher Center for Integrative Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA.

Correspondence regarding original validation datasets and scale development historically centers at the University of California, San Francisco, Division of Prevention Science, Department of Medicine.

Purpose

The emergence of Highly Active Antiretroviral Therapy (HAART) transformed HIV infection from a fatal diagnosis into a manageable chronic illness. However, the therapeutic efficacy of antiretroviral regimens requires near-perfect adherence levels (historically estimated at ≥95% for unboosted regimens, and high sustainment for modern integrase strand transfer inhibitor-based regimens) to maintain complete viral load suppression, prevent the emergence of drug-resistant viral mutations, forestall clinical disease progression to AIDS, and eliminate onward sexual transmission (Undetectable = Untransmittable; U=U). The primary purpose of the HIV-ASES is to quantitatively assess a patient’s subjective confidence in executing and sustaining adherence-related behaviors when confronted with salient systemic, psychological, social, and physiological obstacles.

Adherence to HIV care is complex, encompassing not merely pill swallowing, but also dietary modifications, fluid intake requirements, strict dosing schedules, clinic attendance, laboratory monitoring, pharmacy refills, and lifestyle adjustments including exercise, substance moderation, and nutrition. Traditional self-report surveys often suffer from ceiling effects, social desirability biases, or retrospective recall inaccuracies. By measuring self-efficacy beliefs rather than past behavioral lapses alone, the HIV-ASES identifies psychological vulnerability before clinical nonadherence, virologic rebound, or treatment failure occurs.

In clinical practice, the HIV-ASES serves as an initial diagnostic screening tool that clinicians and case managers deploy to identify domains where a patient feels insecure. For instance, an individual might exhibit elevated efficacy in swallowing medications in private, yet experience severe self-efficacy deficits when required to dose in public or navigate severe medication adverse events. In research paradigms, the scale acts as an essential mediator or outcome variable in randomized controlled trials evaluating cognitive-behavioral, digital health, nursing, or peer-led adherence interventions.

Psychological Construct

The psychological construct evaluated by the HIV-ASES is adherence self-efficacy specific to HIV clinical management. Self-efficacy represents an individual’s perceived capability to organize and execute courses of action required to attain designated types of performances. Within chronic disease models, adherence self-efficacy operates as a dynamic, situation-specific cognitive appraisal rather than a global, immutable personality trait. The HIV-ASES isolates two distinct but intercorrelated construct dimensions:

1. Integration Subscale

The Integration dimension quantifies the patient’s perceived capability to embed treatment demands into their regular social architecture and daily existence without friction or disorganization. Managing chronic illness requires the continuous restructuring of daily schedules, the coordination of domestic routines, and navigation of interpersonal dynamics. Subscale items assess beliefs regarding:

• Incorporating complex pharmacotherapy schedules into fluid daily routines.
• Preserving medication compliance across altered schedules, travel, or occupational disruptions.
• Managing public disclosure concerns and stigmatizing environments (e.g., executing medication administration in the presence of relatives, peers, or colleagues who are unaware of the individual’s HIV status).
• Sustaining regular healthcare engagements, such as overcoming logistics, transportation friction, and clinic appointment scheduling demands.

2. Perseverance Subscale

The Perseverance dimension taps the respondent’s perceived resilience and determination to persist with the therapeutic plan under subjective distress, somatic discomfort, counter-attitudinal interpersonal pressures, or therapeutic ambiguity. This construct captures the motivational grit needed when direct positive reinforcement is absent or when clinical indicators are discouraging. Specific facets include:

• Adhering to prescribed regimens despite disruptive gastrointestinal, neurological, or systemic drug side effects.
• Maintaining fidelity to the medical protocol when feeling acute somatic illness or extreme fatigue.
• Persevering through affective distress, hopelessness, or health-related demoralization.
• Maintaining adherence even when confronting biological setbacks, such as declining CD4+ T-cell counts or delayed clinical improvements.
• Resisting negative interpersonal messaging from social networks, including skepticism or fatalistic advice from close friends and family members.

Theoretical Framework

The HIV-ASES is founded upon Albert Bandura’s Social Cognitive Theory (SCT) (Bandura, 1986, 1997). Under this theoretical architecture, human agency operates through a triadic reciprocal causation model wherein cognitive/affective factors, behavioral patterns, and environmental influences interact bidirectionally. Bandura posits that perceived self-efficacy serves as the central foundation of human agency: unless people believe they can produce desired effects through their actions, they have little incentive to act or persevere when difficulties arise.

SCT delineates a fundamental distinction between efficacy expectations (the belief that one can successfully execute the behavior required to produce the outcomes) and outcome expectancies (the judgment of the likely consequence such behavior will produce). An individual living with HIV may acknowledge that antiretroviral therapy prevents viral replication (high outcome expectancy), yet simultaneously harbor profound doubts regarding their own stamina to take pills every day amidst severe nausea or domestic turmoil (low self-efficacy). The HIV-ASES isolates and measures these efficacy expectations.

According to self-efficacy theory, cognitive appraisals of capability stem from four informational sources:

• Enactive Mastery Experiences: Prior successful navigation of treatment challenges serves as the most powerful source of efficacy. Successful routine integration builds resilient efficacy beliefs.
• Vicarious Experiences: Observing peers or community members who successfully maintain therapeutic regimens under comparable socio-environmental stressors bolsters self-efficacy.
• Verbal and Social Persuasion: Encouragement from treating clinicians, nurses, and support networks can sustain motivation, whereas discouraging remarks from significant others may undermine resolve.
• Physiological and Affective States: Somatic aversive stimuli (e.g., drug side effects, malaise) and negative mood states (e.g., discouragement, depression) are frequently misattributed by patients as indications of personal failure or treatment futility, precipitating regimen abandonment.

The HIV-ASES systematically presents hypothetical and real-world triggers across these four dimensions, quantifying the respondent’s confidence threshold across graded barriers.

Validity

The psychometric validity of the HIV-ASES has been extensively demonstrated across diverse clinical populations, randomized behavioral clinical trials, and epidemiological cohorts internationally.

Construct and Structural Validity

In the foundational psychometric study by Johnson et al. (2007) conducted among 424 HIV-positive individuals initiating or currently prescribed HAART, structural validity was confirmed using both exploratory and confirmatory factor analytic methodologies. The two identified factors—Integration and Perseverance—retained clear, non-overlapping conceptual boundaries while maintaining moderate inter-factor correlation, confirming that they represent distinct facets of a unified self-efficacy construct.

Convergent and Discriminant Validity

Convergent validity has been established by examining associations between the HIV-ASES and theoretically aligned psychological constructs. Scores on the HIV-ASES demonstrate significant positive correlations with:

• General self-efficacy scales and chronic disease management efficacy indices (r = .45 to .62, p < .001).
• Positive treatment outcome expectancies (r = .38 to .51, p < .001).
• Perceived social support and clinician-patient communication quality (r = .30 to .42, p < .001).

Conversely, discriminant validity is substantiated by significant negative correlations with constructs measuring psychological distress and cognitive burden:

• Depressive symptomatology measured via the Center for Epidemiologic Studies Depression Scale (CES-D) or Beck Depression Inventory (BDI) (r = -.35 to -.48, p < .001).
• Perceived HIV-related stigma and internalized discrimination (r = -.28 to -.40, p < .001).
• Perceived stress and generalized anxiety (r = -.32 to -.44, p < .001).

Criterion-Related and Predictive Validity

The clinical utility of the HIV-ASES is underscored by its ability to predict hard behavioral and biological endpoints. Longitudinal investigations have confirmed that higher baseline scores on the HIV-ASES predict significantly higher percentages of prescribed doses taken according to electronic Medication Event Monitoring Systems (MEMS caps), reduced unannounced pill-count discrepancies, and lower self-reported missed doses over 3, 6, and 12-month observation windows. Crucially, multivariate logistic regression analyses demonstrate that individuals scoring in the highest quartile of the HIV-ASES exhibit significantly greater odds of achieving and sustaining viral load suppression (<50 copies/mL) and experiencing upward CD4+ lymphocyte recovery, even after controlling for baseline viral load, substance use disorders, psychiatric comorbidity, and regimen complexity.

Reliability

The HIV-ASES displays exceptional reliability across diverse empirical investigations, demonstrating high internal consistency, temporal stability, and minimal measurement error.

Internal Consistency

In the original validation study by Johnson et al. (2007), the 12-item full scale demonstrated high internal consistency, with an overall Cronbach’s alpha of α = .92. The individual subscales demonstrated equally strong internal consistency coefficients:

• Integration Subscale: Cronbach’s α = .87 to .89.
• Perseverance Subscale: Cronbach’s α = .88 to .91.

Subsequent psychometric investigations evaluating translated versions (including Spanish, French, Portuguese, Chinese, and Swahili adaptations) have replicated these metrics, yielding full-scale Cronbach’s alphas ranging from .89 to .94 and McDonald’s omega (ω) coefficients consistently above .90.

Test-Retest Reliability and Temporal Invariance

Test-retest reliability was evaluated across 1-month and 3-month intervals among clinically stable HIV-positive individuals who received no targeted behavioral interventions. Intraclass correlation coefficients (ICCs) and Pearson correlation coefficients ranged from r = .76 to .83, indicating solid temporal stability. In longitudinal cohort studies involving structural equation modeling (SEM), the instrument showed longitudinal measurement invariance across baseline, post-intervention, and longitudinal follow-up waves, confirming that score shifts reflect true developmental changes in efficacy expectations rather than instrument instability.

Factor Analysis

The structural dimensionality of the HIV-ASES was systematically delineated via Exploratory Factor Analysis (EFA) and validated using Confirmatory Factor Analysis (CFA) by Johnson and colleagues (2007).

Exploratory Factor Analysis (EFA)

Initial principal axis factoring with promax (oblique) rotation was conducted to account for expected correlations between sub-dimensions of treatment self-efficacy. Scree plot evaluation, parallel analysis, and eigenvalues greater than 1.0 converged on a robust two-factor solution accounting for over 58% of the total item variance. Item communalities (h²) were uniformly elevated, spanning .45 to .78, indicating that the items share substantial variance with the latent constructs.

Confirmatory Factor Analysis (CFA)

Confirmatory factor analytic procedures on an independent validation hold-out sample evaluated competing models: a single-factor unidimensional model, an orthogonal two-factor model, and an oblique two-factor model. The oblique two-factor model demonstrated superior goodness-of-fit across standard fit indices:

• Comparative Fit Index (CFI): > .95
• Tucker-Lewis Index (TLI): > .94
• Root Mean Square Error of Approximation (RMSEA): .052 (90% CI [.038, .066])
• Standardized Root Mean Square Residual (SRMR): .041
• Chi-Square / Degrees of Freedom Ratio (χ²/df): < 2.2

Standardized factor loadings across both dimensions were robust, ranging from .62 to .86. The correlation between the Integration latent factor and the Perseverance latent factor was approximately r = .68 (p < .001), indicating related yet conceptually non-redundant dimensions.

Instrument / Measurement Tool

• Test Type: Psychometric self-report rating scale / Patient-Reported Outcome Measure (PROM).
• Administration Format: Paper-and-pencil questionnaire, computer-assisted self-interview (CASI), web-based digital survey, or clinician-administered interview.
• Target Population: Individuals diagnosed with HIV who are currently prescribed, initiating, or re-initiating antiretroviral therapy and associated self-care treatment plans.
• Number of Items: 12 items.
• Factor/Subscale Structure:
  • Integration Subscale: Focuses on embedding the regimen into daily routines, managing public dosing, clinic scheduling, and lifestyle adjustments.
  • Perseverance Subscale: Focuses on maintaining adherence despite adverse drug side effects, feeling sick, emotional discouragement, poor clinical markers, or negative social influence.
• Response Scale: 11-point continuous visual numeric response scale ranging from 0 (“Cannot do at all”) through 5 (“Moderately certain can do”) to 10 (“Completely certain can do”).
• Scoring Procedures:
  • Subscale Scores: Calculated by averaging the item scores corresponding to each subscale (sum of subscale items divided by the number of completed items in that subscale), yielding a score ranging from 0 to 10.
  • Total Score: Calculated by taking the mean across all 12 items (sum of all 12 items divided by 12), with possible scores ranging from 0 to 10. Alternatively, sum scores (range 0 to 120) can be calculated if no items are missing.
  • Directionality: Higher scores denote greater adherence self-efficacy and higher perceived confidence in overcoming adherence barriers. Lower scores reflect vulnerability to treatment nonadherence.
• Completion Time: Approximately 3 to 5 minutes.

Permissions & Fee and Test Year

The HIV Treatment Adherence Self-Efficacy Scale was formally published in 2007 by Johnson and colleagues in the Journal of Behavioral Medicine. The instrument was developed with public federal research grant funding supported by the National Institutes of Health (NIH), including grants from the National Institute of Mental Health (NIMH).

Permissions and Accessibility: The HIV-ASES is in the public domain for academic, clinical, and non-commercial research purposes. Researchers and clinicians may utilize, administer, and reproduce the measure without paying licensing fees or royalties. The authors request that standard academic attribution and citations to the primary validation study (Johnson et al., 2007) be maintained in all research publications, conference presentations, and technical reports. Modification of item phrasing or translation into other languages should follow formal forward-backward translation protocols and cross-cultural psychometric validation guidelines.

References

• Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.
• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman.
• Chesney, M. A., Ickovics, J. R., Chambers, D. B., Gifford, A. L., Neidig, J., Zwickl, B., & Wu, A. W. (2000). Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: The AACTG adherence instruments. AIDS Care, 12(3), 255–266. https://doi.org/10.1080/09540120050042917
• Johnson, M. O., Neilands, T. B., Dilworth, S. E., Morin, S. F., Remien, R. H., & Chesney, M. A. (2007). The role of self-efficacy in HIV treatment adherence: Validation of the HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES). Journal of Behavioral Medicine, 30(5), 359–370. https://doi.org/10.1007/s10865-007-9118-3
• Remien, R. H., Bastos, F. I., Berkman, A., Tais, N. L. S., Raxach, J. C., Parker, R. G., & Malow, R. M. (2007). Universal access to antiretroviral therapy in Brazil: Does it promote or hinder adherence? AIDS and Behavior, 11(5), 67–76. https://doi.org/10.1007/s10461-006-9199-0
• Simoni, J. M., Frick, P. A., & Huang, B. (2006). A longitudinal evaluation of a social support model of medication adherence among HIV-positive men and women on antiretroviral therapy. Health Psychology, 25(1), 74–81. https://doi.org/10.1037/0278-6133.25.1.74

Items of the Scale