We sought to review the effectiveness of interventions designed to improve adherence to antiretroviral therapy (ART) from studies included in a recent Cochrane review that reported a clinical and an adherence outcome, with at least 80% follow-up for 6 months or more Data were extracted independently and in duplicate, with an adjudicator for disagreements Risk of bias was assessed using the Cochrane Risk of Bias tool Of 182 relevant studies in the Cochrane review, 49 were related to ART Statistical pooling was not warranted due to heterogeneity in interventions, participants, treatments, adherence measures and outcomes Many studies had high risk of bias in elements of design and outcome ascertainment Only 10 studies improved both adherence and clinical outcomes These used the following interventions: adherence counselling (two studies); a once-daily regimen (compared to twice daily); text messaging; web-based cognitive behavioral intervention; face-to-face multi-session intensive behavioral interventions (two studies); contingency management; modified directly observed therapy; and nurse-delivered home visits combined with telephone calls Patient-related adherence interventions were the most frequently tested Uniform adherence measures and higher quality studies of younger populations are encouraged

/pdf/interventions-for-enhancing-adherence-to-antiretroviral-18c8qe6hls.pdf

Interventions for Enhancing Adherence to Antiretroviral Therapy (ART): A Systematic Review of High Quality Studies

Background Human immunodeficiency virus (HIV)-infected women are at risk of virologic failure postpartum. We evaluated factors influencing retention in care and viral suppression in postpartum HIV-infected women. Methods We conducted a retrospective cohort analysis (2005-2011) of 695 deliveries involving 561 HIV-infected women in Philadelphia. Multivariable logistic regression evaluated factors, including maternal age, race/ethnicity, substance use, antiretroviral therapy during pregnancy, timing of HIV diagnosis, previous pregnancy with HIV, adequacy of prenatal care, and postpartum HIV care engagement (≥ 1 CD4 count or viral load [VL] test within 90 days of delivery), associated with retention in care (≥ 1 CD4 count or VL test in each 6-month interval of the period with ≥ 60 days between tests) and viral suppression (VL ≤ 200 copies/mL at the last measure in the period) at 1 and 2 years postpartum. Results Overall, 38% of women engaged in HIV care within 90 days postpartum; with 39% and 31% retained in care and virally suppressed, respectively, at 1 year postpartum, and 25% and 34% retained in care and virally suppressed, respectively, at 2 years postpartum. In multivariable analyses, women who engaged in HIV care within 90 days of delivery were more likely to be retained (adjusted odds ratio [AOR], 11.38; 95% confidence interval [CI], 7.74-16.68) and suppressed (AOR, 2.60 [95% CI, 1.82-3.73]) at 1 year postpartum. This association persisted in the second year postpartum for both retention (AOR, 6.19 [95% CI, 4.04-9.50]) and suppression (AOR, 1.40 [95% CI, 1.01-1.95]). Conclusions The prevalence of postpartum HIV-infected women retained in care and maintaining viral suppression is low. Interventions seeking to engage women in care shortly after delivery have the potential to improve clinical outcomes.

Postpartum Engagement in HIV Care: An Important Predictor of Long-term Retention in Care and Viral Suppression

Background Poor adherence is the result of many barriers. Most of the adherence research has focused on the patients' hurdles to adherence, instead of the responsibility the physician has for assuring adherence to treatment. Objective The purpose of this review is to identify barriers to medication adherence and refocus how we describe those barriers in terms of physician behavior hurdles. Methods PubMed was systematically searched for systematic reviews published between January 01, 2010, and December 06, 2017, that provided barriers to medication adherence. The searches were limited to reviews having adherence to medication prescribed in the outpatient setting as the main topic. Results Thirty-one reviews were included in this review, covering 13 different disease categories. Fifty-eight different barriers to adherence to medications for chronic conditions were identified. Nineteen barriers were cited 6 or more times, and these were further categorized based on the World Health Organization's 5 dimensions of adherence and the number of times cited. Conclusion This review provides clear evidence that adherence to medication is affected by multiple barriers. To facilitate this, adherence barriers can be framed as physician/health system hurdles. With that focus in mind, we may put the responsibility where we have the most control.

/pdf/barriers-to-treatment-describing-them-from-a-different-1yh5aj4nla.pdf

Barriers to treatment: describing them from a different perspective.

HIV remains a key public health issue, despite the introduction of effective antiretroviral therapy (ART) which has led to huge improvements in the prognosis of HIV-positive individuals. In order to be best informed about an HIV epidemic, it is desirable to have estimates to complement data already available from national and international surveillance, not only on the total number of people living with HIV, but which also describe the characteristics of HIV-positive populations such as the number diagnosed, CD4 count and viral load distribution and the cascade of care. The aims of this thesis were to develop a method based on an individual-based progression model of HIV and the effect of ART to reconstruct and hence better understand the HIV-positive population, for use in Europe. Using this model, I first investigated the projected life expectancy of men-who-have-sex-with-men (MSM) according to timing of diagnosis. I then updated the model to incorporate new data after a review of the literature as well as statistical analyses of viral load and CD4 count changes in the absence of ART, based on data from a large pan-European cohort collaboration. Next, I developed a method using data on MSM in the UK, which calibrates the model to observational and surveillance data of HIV from European countries, and then uses the parameter sets which best fit to the observed data to describe the status of their HIV-positive populations. Plausibility ranges are also estimated to reflect the uncertainty regarding any model parameters. The method is also applied to data on MSM in the Netherlands, and for all HIV-positive individuals in Spain and Estonia. The advantages and disadvantages of this approach compared with other existing approaches are considered. To conclude, I reflect on future modelling needs that are particularly relevant to informing public health in Europe.

Estimation of the size and characteristics of HIV-positive populations in Europe

Antiretroviral therapy (ART) is used to suppress the HIV viral load but requires optimal adherence to be effective. This study examined the factors influencing ART adherence among HIV-positive clients in the Ga West Municipality, Ghana using the Health Belief Model (HBM).A facility-based cross-sectional design was adopted among 397 HIV clients aged 18 years and above. Data were collected using an interviewer-administered questionnaire and analysed using Stata version 16.0. Binary logistic regression was performed at the P < 0.05 level.Adherence to ART was 44.6%. Clients who took less than 30 minutes to reach ART sites were 59% less likely to adhere to ART (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.20-0.82). Clients who thought they lost income when they went to obtain their ART refill were more likely to adhere to ART (OR 1.71, 95% CI 1.04-2.83), as were those who developed side effects (OR 1.74, 95% CI 1.05-2.89) (perceived barriers). Clients who had confidence in their ability to take their medications (self-efficacy) (OR 1.86, 95% CI 1.05-3.31) and those who received reminders from health workers (cues to action) (OR 1.91, 95% CI 1.04-3.53) were more likely to adhere to ART.Interventions should focus on increasing client confidence in adhering to ART. Providers should be empowered to provide reminders to patients. 

Factors influencing adherence to antiretroviral therapy among HIV/AIDS patients in the Ga West Municipality, Ghana

Adherence to antiretroviral therapy (ART) is crucial for effective treatment, but can be quite complex. Non-adherence can adversely affect treatment outcomes. Although many studies have been done on adherence in the general population, few have included HIV-positive pregnant and postpartum women in resource-constrained settings. This review assessed the evidence on adherence among these groups of women. A systematic search of databases was completed between June and July 2011. Both qualitative and quantitative studies were included. Eighteen studies from a total of 6622 satisfied the inclusion criteria that included inter alia facilitators and barriers to adherence. This review highlighted that there is still no consensus on the definition and measurement of adherence; also multiple factors can affect a woman's ability to adhere to ART. Some of the barriers and facilitators identified were similar in both the type of study (qualitative and quantitative) and among the various countries. Findings indicated that the few studies in this population are conducted primarily in resource-rich settings. Such paucity of information warrants urgent attention; thus targeted research is needed to provide insight on adherence within this population.

Factors affecting antiretroviral therapy adherence among HIV-positive pregnant and postpartum women: an adapted systematic review

South Africa has one of the lowest breastfeeding rates on the African continent. Globally, just 44% of infants are breastfed soon after birth, and 40% of those less than six months old are exclusively breastfed. To improve infant nutrition by 2025, the United Nations established targets to eliminate malnutrition and increase exclusive breastfeeding (EBF) rates to at least 50%. Despite the WHO Code regulations endorsed by the World Health Assembly since 1981, breaches continue to be prevalent due to a combination of weak implementation, monitoring and enforcement in low-to-middle income countries. Over the years, infant formula sales in LMICs (including South Africa) have skyrocketed contributing to excess infant morbidity and mortality. To that end, the specific aims of this study was to gain an understanding of priority actions and strategies necessary to improve breastfeeding outcomes in South Africa in the context of the HIV pandemic. The team used a qualitative study design based on a semi-structured interview guide. The guide consisted of eight open-ended questions addressing the WHO HIV-related infant feeding guidelines, the WHO International Code of Marketing of Breastmilk Substitutes, political will, and advocacy. Of the 24 individuals contacted, 19 responded and 15 agreed to participate. The Breastfeeding Gear Model guided the thematic analysis. The three main themes identified were 1) WHO guidelines on HIV and infant feeding, 2) Improving exclusive breastfeeding, and 3) Advocacy. Key informants identified issues that need to be addressed to improve breastfeeding outcomes in South Africa. Strong political will is a key ingredient to harness the resources (human, financial) needed to implement, monitor, and act against Code violators. South Africa and other countries with similar challenges should consider using the WHOs Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes and Subsequent relevant World Health Assembly Resolutions (NetCode) methodology.

/pdf/gearing-up-to-improve-exclusive-breastfeeding-practices-in-3scb9h2f.pdf

Gearing up to improve exclusive breastfeeding practices in South Africa

The Caribbean region has the second highest HIV prevalence after Sub-Saharan Africa. Guyana's adult HIV prevalence is 1.9% among pregnant women, with women accounting for an estimated 58% of all persons living with HIV. However, there are few studies on ART adherence in the Caribbean, none from Guyana, and none focusing on adherence in pregnancy and the postpartum period. The objective of this study was to explore the perspectives of HIV-infected pregnant and postpartum women and healthcare providers in Guyana about barriers and facilitators to ART adherence. Data was collected using semi-structured interviews with 24 HIV-infected pregnant and postpartum women and nine healthcare professionals at five clinics between February and April 2012. The Framework Method for analysing qualitative data identified facilitators and barriers related to five core themes: (i) Concern for wellbeing of children; (ii) ART-related factors; (iii) Disclosure; (iv) Socio-economic issues; and (v) Religious and cultural beliefs. Non-disclosure did not adversely affect adherence, contrary to other studies in the literature. Two broad categories emerged from the lived experiences of women in Guyana. The first is related to the act of actually taking their medication where their tenacity is displayed in efforts made to ensure ART is taken. The second relates to the significance of ART to them in terms of reduced risk of MTCT, and the possibility of better health for themselves to enable them to care for their children. However, issues related to poverty, food insecurity and side effects reduced adherence need to be adequately addressed.

https://journals.sagepub.com/doi/pdf/10.1177/2325957416680297

Antiretroviral Adherence Perspectives of Pregnant and Postpartum Women in Guyana.

Barriers to antiretroviral therapy (ART) adherence among pregnant women are varied and complex. This study explored the constructs of a theoretical model, the Health Belief Model (HBM) to understand and predict ART adherence among pregnant women in Guyana. A cross-sectional study surveyed 108 pregnant women attending 11 primary care clinics. ART adherence ranging from the past weekend to three months was assessed through self-reports, and health beliefs with the Adherence Determinants Questionnaire (ADQ). Constructs with sufficient variation in responses were tested for association with the level of adherence using Spearman's rank correlation coefficient and test. Sixty-seven per cent (72) of the women reported being always adherent. Although there was positive endorsement of ART treatment and adherence, the HBM did not help in understanding or predicting ART adherence in this population. Only one item from the perceived susceptibility construct was significantly associated (p = 0.009) with adherence. Interventions are warranted to address ART adherence in this population, as 19% of the women were recently non-adherent. Although the ADQ did not contribute to a deeper understanding or provide insight into pathways that can be targeted for intervention, theoretical models can play a key role in identifying these pathways.

Predicting adherence to antiretroviral therapy among pregnant women in Guyana: Utility of the Health Belief Model.

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Factors affecting antiretroviral therapy adherence among HIV-positive pregnant and postpartum women: an adapted systematic review

Gearing up to improve exclusive breastfeeding practices in South Africa

Antiretroviral Adherence Perspectives of Pregnant and Postpartum Women in Guyana.

Predicting adherence to antiretroviral therapy among pregnant women in Guyana: Utility of the Health Belief Model.