Adherence to antiretroviral therapy for HIV/AIDS in Latin America and the Caribbean: Systematic review and meta‐analysis

Abstract

IntroductionOptimal adherence to antiretroviral therapy is closely related with suppression of the HIV viral load in plasma, slowing disease progression and decreasing HIV transmission rates. Despite its importance, the estimated proportion of people living with HIV in Latin America and the Caribbean with optimal adherence has not yet been reported in a meta‐analysis. Moreover, little is known of the factors leading to poor adherence which may be setting‐specific. We present a pooled estimate of adherence to antiretroviral therapy (ART) of people living with HIV in Latin America and Caribbean, report the methods used to measure adherence and describe the factors associated with poor adherence among the selected studies.MethodsWe electronically searched published studies up to July 2016 on the PubMed, Web of Science and Virtual Health Library (Latin America and the Caribbean Regional Portal); considering the following databases: MEDLINE, LILACS, PAHO and IBECS. Two independent reviewers selected and extracted data on ART adherence and study characteristics. Pooled estimate of adherence was derived using a random‐effects model. Risk of bias in individual studies was assessed independently by two investigators using the Risk of Bias Assessment tool for Non‐randomized Studies (RoBANS).Results and discussionThe meta‐analysis included 53 studies published between 2005 and 2016, which analysed 22,603 people living with HIV in 25 Latin America and Caribbean countries. Overall adherence in Latin America and Caribbean was 70% (95% CI: 63–76; I 2 = 98%), similar to levels identified by studies conducted in high‐income regions. Self‐report was the most frequently used method to measure adherence. Subgroup analysis showed that adherence was higher for the shortest recall time frame used, as well as in countries with lower income level, Gross National Income (GNI) per capita and Human Development Index (HDI). Studies reported diverse adherence barriers, such as alcohol and substance misuse, depression, unemployment and pill burden.ConclusionsOur study suggests that adherence to ART in Latin America and Caribbean may be below the sufficient levels required for a successful long‐term viral load suppression.

Evidence of Validity for the Online Version of the Assessment of Adherence to Antiretroviral Therapy Questionnaire

“…Nevertheless, there is evidence (e.g., Rolnick, Pawloski, Hedblom, Asche, & Bruzek, 2013;World Health Organization, 2003) that some patient characteristics may indicate more risk to experience difficulties with treatment adherence. Our results indicated that age was positively associated with adherence level (similar results were reported by Biello et al, 2016), gender was associated with adherence scores (male scores were slightly higher than female scores; similar results were described in Costa et al, 2018), and education level was related to better doctor-patient communication (also reported in Pérez-Salgado et al, 2015). Patients with better formal education may connect more easily with their doctor or feel less distant or uncomfortable with health care personnel.…”

“…Although some authors (e.g., Costa et al, 2018) claim that self-reports may overestimate adherence due to social desirability (i.e., the tendency of survey respondents to answer questions in a way that will be viewed favorably by others) and recall biases, other authors (e.g., Simoni et al, 2006;Thirumurthy et al, 2012) recognize that individual selfreports can be inexpensive, easy to administer, and accurately identify medication-taking behavior. Therefore, the availability of measures that are robust in terms of psychometric properties is very much needed to minimize limitations attributed to self-report instruments.…”

“…Adherence to HIV treatment is a complex and multifaceted behavior (Remor, 2013b), and can be understood as the extent to which one's behavior coincides with the health recommendations he or she receives (Haynes, Taylor, & Sackett, 1979). However, associations between adherence levels and health outcomes are complex; many mediators may be implicated, including time in treatment, psychological variables, quality of the provided treatment, patient age, and viral load levels (Costa, Torres, Coelho, & Luz, 2018;Marks et al, 2015;Remor, Penedo, Shen, & Schneiderman, 2007). Psychosocial aspects should also be investigated, because they may act as barriers or facilitators to the adherence process (Biello et al, 2016;Costa et al, 2018;Dima, Schweitzer, Diaconiţ, Remor, & Wanless, 2013).…”

“…However, associations between adherence levels and health outcomes are complex; many mediators may be implicated, including time in treatment, psychological variables, quality of the provided treatment, patient age, and viral load levels (Costa, Torres, Coelho, & Luz, 2018;Marks et al, 2015;Remor, Penedo, Shen, & Schneiderman, 2007). Psychosocial aspects should also be investigated, because they may act as barriers or facilitators to the adherence process (Biello et al, 2016;Costa et al, 2018;Dima, Schweitzer, Diaconiţ, Remor, & Wanless, 2013). The combination of drug treatments and psychosocial approaches allows for various vulnerabilities to which people with HIV are exposed to be addressed.…”

Rapid initiation of antiretroviral therapy at HIV diagnosis: definition, process, knowledge gaps

“…In LMICs, rapid‐start ART is working towards the UNAIDS 90‐90‐90 goal , although there are some signs that rapid‐start ART may not meet targets for long‐term viral suppression . This may be a consequence of restricted access to viral load monitoring, relatively inefficient ART regimens, poor linkage to/retention in care and limited care provision rather than the speed of ART initiation per se . Challenges remain in ongoing provision of ART in LMICs that are beyond the scope of this article .…”