Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations

Jessica E. Haberer, Lora Sabin, K. Rivet Amico, Catherine Orrell, Omar Galárraga, Alexander C. Tsai, Rachel C. Vreeman, Ira Wilson, Nadia A. Sam-Agudu, Terrence F. Blaschke, Bernard Vrijens, Claude A. Mellins, Robert H. Remien, Sheri D. Weiser, Elizabeth Lowenthal, Michael J. Stirratt, Papa Salif Sow, Bruce Thomas, Nathan Ford, Edward MillsRichard Lester, Jean B. Nachega, Bosco Mwebesa Bwana, Fred Ssewamala, Lawrence Mbuagbaw, Paula Munderi, Elvin Geng, David Bangsberg

Research output: Contribution to journalArticle

59 Citations (Scopus)

Abstract

Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.

Original languageEnglish (US)
Number of pages1
JournalJournal of the International AIDS Society
Volume20
Issue number1
DOIs
StatePublished - 2017

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Counseling
Therapeutics
Acquired Immunodeficiency Syndrome
HIV
Text Messaging
Technology
Delivery of Health Care
Public Policy
Meta-Analysis
Motivation
Randomized Controlled Trials
Public Health
Communication
Economics
Guidelines
Education
Research
Population

Keywords

  • antiretroviral therapy adherence
  • HIV
  • interventions
  • resource-limited settings

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Infectious Diseases

Cite this

Improving antiretroviral therapy adherence in resource-limited settings at scale : a discussion of interventions and recommendations. / Haberer, Jessica E.; Sabin, Lora; Amico, K. Rivet; Orrell, Catherine; Galárraga, Omar; Tsai, Alexander C.; Vreeman, Rachel C.; Wilson, Ira; Sam-Agudu, Nadia A.; Blaschke, Terrence F.; Vrijens, Bernard; Mellins, Claude A.; Remien, Robert H.; Weiser, Sheri D.; Lowenthal, Elizabeth; Stirratt, Michael J.; Sow, Papa Salif; Thomas, Bruce; Ford, Nathan; Mills, Edward; Lester, Richard; Nachega, Jean B.; Bwana, Bosco Mwebesa; Ssewamala, Fred; Mbuagbaw, Lawrence; Munderi, Paula; Geng, Elvin; Bangsberg, David.

In: Journal of the International AIDS Society, Vol. 20, No. 1, 2017.

Research output: Contribution to journalArticle

Haberer, JE, Sabin, L, Amico, KR, Orrell, C, Galárraga, O, Tsai, AC, Vreeman, RC, Wilson, I, Sam-Agudu, NA, Blaschke, TF, Vrijens, B, Mellins, CA, Remien, RH, Weiser, SD, Lowenthal, E, Stirratt, MJ, Sow, PS, Thomas, B, Ford, N, Mills, E, Lester, R, Nachega, JB, Bwana, BM, Ssewamala, F, Mbuagbaw, L, Munderi, P, Geng, E & Bangsberg, D 2017, 'Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations', Journal of the International AIDS Society, vol. 20, no. 1. https://doi.org/10.7448/IAS.20.1/21371
Haberer, Jessica E. ; Sabin, Lora ; Amico, K. Rivet ; Orrell, Catherine ; Galárraga, Omar ; Tsai, Alexander C. ; Vreeman, Rachel C. ; Wilson, Ira ; Sam-Agudu, Nadia A. ; Blaschke, Terrence F. ; Vrijens, Bernard ; Mellins, Claude A. ; Remien, Robert H. ; Weiser, Sheri D. ; Lowenthal, Elizabeth ; Stirratt, Michael J. ; Sow, Papa Salif ; Thomas, Bruce ; Ford, Nathan ; Mills, Edward ; Lester, Richard ; Nachega, Jean B. ; Bwana, Bosco Mwebesa ; Ssewamala, Fred ; Mbuagbaw, Lawrence ; Munderi, Paula ; Geng, Elvin ; Bangsberg, David. / Improving antiretroviral therapy adherence in resource-limited settings at scale : a discussion of interventions and recommendations. In: Journal of the International AIDS Society. 2017 ; Vol. 20, No. 1.
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T2 - a discussion of interventions and recommendations

AU - Haberer, Jessica E.

AU - Sabin, Lora

AU - Amico, K. Rivet

AU - Orrell, Catherine

AU - Galárraga, Omar

AU - Tsai, Alexander C.

AU - Vreeman, Rachel C.

AU - Wilson, Ira

AU - Sam-Agudu, Nadia A.

AU - Blaschke, Terrence F.

AU - Vrijens, Bernard

AU - Mellins, Claude A.

AU - Remien, Robert H.

AU - Weiser, Sheri D.

AU - Lowenthal, Elizabeth

AU - Stirratt, Michael J.

AU - Sow, Papa Salif

AU - Thomas, Bruce

AU - Ford, Nathan

AU - Mills, Edward

AU - Lester, Richard

AU - Nachega, Jean B.

AU - Bwana, Bosco Mwebesa

AU - Ssewamala, Fred

AU - Mbuagbaw, Lawrence

AU - Munderi, Paula

AU - Geng, Elvin

AU - Bangsberg, David

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N2 - Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.

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