Uestions were adapted from validated patient self-report survey instruments [9,10]. We converted responses for each question to a 0- to 10-point scale. Overall patient satisfaction was measured by averaging the response values of these 2 questions. Construct reliability was evaluated by calculating composite reliability and average variance extracted. We used recommended thresholds of 0.70 and 0.50, respectively [11?4]. Medication adherence. A validated, single-item measure assessed adherence to HAART. The item stated, “Many patients find it hard to take HIV medicines as their doctor prescribes them. In the past 4 weeks, how would you rate your ability to take all your HIV medicines as your doctor prescribed?” The 6-point response scale ranged from “very poor” to “excellent” [15,16]. This item has been 
validated against medication event monitoring system data, an objective measure of adherence [15], and has anOverall patient satisfaction.Relationship between Patient Satisfaction and Adherence to HIV Care. We compared overall patient satisfaction scoresbetween participants with adequate versus inadequate retention in HIV care, “excellent” versus non-“excellent” adherence to HAART, and suppressed versus unsuppressed HIV replication using 1655472 the Wilcoxon Rank-Sum Test. 14636-12-5 Bivariate analyses. We performed bivariate analyses between potential control variables (demographic, health status, behavioral characteristics, and clinic utilization variables listed in Table 1) and all CASIN web dependent variables in the structural equation model (patient satisfaction, retention in HIV care, adherence to HAART and HIV suppression). To be parsimonious in selecting control variables, we included only variables achieving a significance level of p,0.10 in bivariate analyses with at least 2 of the 4 dependent variables. Structural equation modeling. We used structural equation modeling (SEM) to examine hypothesized relationships between patient satisfaction, retention in HIV care, adherence to HAART, and HIV suppression. SEM is a multivariate statistical method that: 1) inputs empirical data and qualitative causal assumptions from theory-based models, 2) allows for the simultaneousPatient Satisfaction to Improve HIV AdherenceTable 1. Baseline characteristics of participants (N = 489).Table 2. Correlation Matrix.aCharacteristics Age, years ?mean (6SD) Gender ?( ) Male Female Race ethnicity ?( ) Non-Hispanic black Non-Hispanic white Hispanic Other Survey mode ?( 1662274 ) Self-administered Interviewer-administered Education ?( ) Some high school or less High school graduate or equivalent Some college of higher Household income ?( ) # 10K . 10K and # 30K . 30K Depression screen, positive ?( ) Alcohol screen, positive ?( ) Illegal or Rx drug abuse screen, positive ?( ) Health status ?( ) Poor/fair Good/very good Excellent HIV risk factor ?( ) IVDA MSM, no IVDA Heterosexual sex, no IVDA Transfusion Currently prescribed HAART ?( ) Duration 
enrolled in clinic, years ?mean (6SD) CD4 counta ?median (25th, 75th percentiles) 16 33 50 ,1 94 7.6 (64.5) 449 (276, 665) 20 65 15 54 36 10 43 42 19 22 35 43 85 15 61 15 21 3 71 29 2 3 4 5 48 (611) 1 Likelihood of recommending clinic Feelings about care Adherence to HAART Retention in HIV care HIV suppression1 1.00 0.53** 0.11* 0.17 0.** *1.00 0.17** 0.08 0.09 1.00 0.12* 0.26** 1.00 0.26** 1.a Partial correlations controlling for age, race ethnicity, depression, and health status. *p,0.05; **p,0.01. doi:10.1371/journal.pone.0054729.tSD ind.Uestions were adapted from validated patient self-report survey instruments [9,10]. We converted responses for each question to a 0- to 10-point scale. Overall patient satisfaction was measured by averaging the response values of these 2 questions. Construct reliability was evaluated by calculating composite reliability and average variance extracted. We used recommended thresholds of 0.70 and 0.50, respectively [11?4]. Medication adherence. A validated, single-item measure assessed adherence to HAART. The item stated, “Many patients find it hard to take HIV medicines as their doctor prescribes them. In the past 4 weeks, how would you rate your ability to take all your HIV medicines as your doctor prescribed?” The 6-point response scale ranged from “very poor” to “excellent” [15,16]. This item has been validated against medication event monitoring system data, an objective measure of adherence [15], and has anOverall patient satisfaction.Relationship between Patient Satisfaction and Adherence to HIV Care. We compared overall patient satisfaction scoresbetween participants with adequate versus inadequate retention in HIV care, “excellent” versus non-“excellent” adherence to HAART, and suppressed versus unsuppressed HIV replication using 1655472 the Wilcoxon Rank-Sum Test. Bivariate analyses. We performed bivariate analyses between potential control variables (demographic, health status, behavioral characteristics, and clinic utilization variables listed in Table 1) and all dependent variables in the structural equation model (patient satisfaction, retention in HIV care, adherence to HAART and HIV suppression). To be parsimonious in selecting control variables, we included only variables achieving a significance level of p,0.10 in bivariate analyses with at least 2 of the 4 dependent variables. Structural equation modeling. We used structural equation modeling (SEM) to examine hypothesized relationships between patient satisfaction, retention in HIV care, adherence to HAART, and HIV suppression. SEM is a multivariate statistical method that: 1) inputs empirical data and qualitative causal assumptions from theory-based models, 2) allows for the simultaneousPatient Satisfaction to Improve HIV AdherenceTable 1. Baseline characteristics of participants (N = 489).Table 2. Correlation Matrix.aCharacteristics Age, years ?mean (6SD) Gender ?( ) Male Female Race ethnicity ?( ) Non-Hispanic black Non-Hispanic white Hispanic Other Survey mode ?( 1662274 ) Self-administered Interviewer-administered Education ?( ) Some high school or less High school graduate or equivalent Some college of higher Household income ?( ) # 10K . 10K and # 30K . 30K Depression screen, positive ?( ) Alcohol screen, positive ?( ) Illegal or Rx drug abuse screen, positive ?( ) Health status ?( ) Poor/fair Good/very good Excellent HIV risk factor ?( ) IVDA MSM, no IVDA Heterosexual sex, no IVDA Transfusion Currently prescribed HAART ?( ) Duration enrolled in clinic, years ?mean (6SD) CD4 counta ?median (25th, 75th percentiles) 16 33 50 ,1 94 7.6 (64.5) 449 (276, 665) 20 65 15 54 36 10 43 42 19 22 35 43 85 15 61 15 21 3 71 29 2 3 4 5 48 (611) 1 Likelihood of recommending clinic Feelings about care Adherence to HAART Retention in HIV care HIV suppression1 1.00 0.53** 0.11* 0.17 0.** *1.00 0.17** 0.08 0.09 1.00 0.12* 0.26** 1.00 0.26** 1.a Partial correlations controlling for age, race ethnicity, depression, and health status. *p,0.05; **p,0.01. doi:10.1371/journal.pone.0054729.tSD ind.
