Patient-Reported Barriers to Adherence to Antiretroviral Therapy: A Systematic Review and Meta-Analysis

Abstract

BackgroundMaintaining high levels of adherence to antiretroviral therapy (ART) is a challenge across settings and populations. Understanding the relative importance of different barriers to adherence will help inform the targeting of different interventions and future research priorities.Methods and FindingsWe searched MEDLINE via PubMed, Embase, Web of Science, and PsychINFO from 01 January 1997 to 31 March 2016 for studies reporting barriers to adherence to ART. We calculated pooled proportions of reported barriers to adherence per age group (adults, adolescents, and children). We included data from 125 studies that provided information about adherence barriers for 17,061 adults, 1,099 children, and 856 adolescents. We assessed differences according to geographical location and level of economic development. The most frequently reported individual barriers included forgetting (adults 41.4%, 95% CI 37.3%–45.4%; adolescents 63.1%, 95% CI 46.3%–80.0%; children/caregivers 29.2%, 95% CI 20.1%–38.4%), being away from home (adults 30.4%, 95% CI 25.5%–35.2%; adolescents 40.7%, 95% CI 25.7%–55.6%; children/caregivers 18.5%, 95% CI 10.3%–26.8%), and a change to daily routine (adults 28.0%, 95% CI 20.9%–35.0%; adolescents 32.4%, 95% CI 0%–75.0%; children/caregivers 26.3%, 95% CI 15.3%–37.4%). Depression was reported as a barrier to adherence by more than 15% of patients across all age categories (adults 15.5%, 95% CI 12.8%–18.3%; adolescents 25.7%, 95% CI 17.7%–33.6%; children 15.1%, 95% CI 3.9%–26.3%), while alcohol/substance misuse was commonly reported by adults (12.9%, 95% CI 9.7%–16.1%) and adolescents (28.8%, 95% CI 11.8%–45.8%). Secrecy/stigma was a commonly cited barrier to adherence, reported by more than 10% of adults and children across all regions (adults 13.6%, 95% CI 11.9%–15.3%; children/caregivers 22.3%, 95% CI 10.2%–34.5%). Among adults, feeling sick (15.9%, 95% CI 13.0%–18.8%) was a more commonly cited barrier to adherence than feeling well (9.3%, 95% CI 7.2%–11.4%). Health service–related barriers, including distance to clinic (adults 17.5%, 95% CI 13.0%–21.9%) and stock outs (adults 16.1%, 95% CI 11.7%–20.4%), were also frequently reported. Limitations of this review relate to the fact that included studies differed in approaches to assessing adherence barriers and included variable durations of follow up. Studies that report self-reported adherence will likely underestimate the frequency of non-adherence. For children, barriers were mainly reported by caregivers, which may not correspond to the most important barriers faced by children.ConclusionsPatients on ART face multiple barriers to adherence, and no single intervention will be sufficient to ensure that high levels of adherence to treatment and virological suppression are sustained. For maximum efficacy, health providers should consider a more triaged approach that first identifies patients at risk of poor adherence and then seeks to establish the support that is needed to overcome the most important barriers to adherence.

Adherence to Nucleos(t)ide Analogue Therapies for Chronic Hepatitis B Infection: A Systematic Review and Meta‐Analysis

“…Our review suggests that suboptimal adherence is an important concern deserving attention. Few studies reported reasons for suboptimal adherence, but the limited information available is consistent with what is known for adherence to HIV medication, where the most commonly reported barriers to adherence include forgetting, change to routine, secrecy/stigma, distance to clinic, being busy, and stock outs . This suggests that interventions to improve adherence to medication for HIV and other chronic infectious diseases may work for chronic HBV infection.…”

“…There is no gold standard for measuring adherence, and while viral load is considered to be the preferred measure, viral load can be influenced by factors other than adherence, including drug efficacy, polypharmacy, drug resistance, treatment failure, and unknown effects of the disease or drugs. For this reason, we did not include studies that reported viral load as the only adherence measure, and it would be valuable to summarize estimates of viral suppression separately to estimates of adherence, as has been done for HIV . We also did not look at biochemical response (as defined by normalization of liver aminotransferase levels), which is influenced by other infectious diseases and chronic liver disease (especially nonalcoholic fatty liver disease in high‐income countries).…”

“…For this reason, we did not include studies that reported viral load as the only adherence measure, and it would be valuable to summarize estimates of viral suppression separately to estimates of adherence, as has been done for HIV. (7,44,45) We also did not look at biochemical response (as defined by normalization of liver aminotransferase levels), which is influenced by other infectious diseases and chronic liver disease (especially nonalcoholic fatty liver disease in high-income countries).…”

“…Few studies reported reasons for suboptimal adherence, but the limited information available is consistent with what is known for adherence to HIV medication, where the most commonly reported barriers to adherence include forgetting, change to routine, secrecy/stigma, distance to clinic, being busy, and stock outs. (45) This suggests that interventions to improve adherence to medication for HIV and other chronic infectious diseases may work for chronic HBV infection. Findings from a recent study suggest that text messaging could improve adherence to chronic HBV infection (47) ; this is consistent with the larger body of evidence supporting text messaging to improve adherence to antiretrovirals for HIV.…”

Adherence status of HIV infected children at ART centre of South India

“…12,13 Adherence is a complex health behavior that is influenced by the drug regimen, patient and family factors, and patient-provider relationship. 14,15 The limited availability of once-daily and single-tablet regimens and palatable formulations for infants and young children is especially problematic. 16 Still achieving such a level of adherence shows the effective implementation of Programme.…”