Short- and long-term efficacy of modified directly observed antiretroviral treatment in Mombasa, Kenya: a randomized trial

Effect of directly observed therapy for highly active antiretroviral therapy on virologic, immunologic, and adherence outcomes: a meta-analysis and systematic review

INTRODUCTION

Directly observed therapy of highly active antiretroviral therapy (DOT-HAART) is a feasible adherence intervention. Prospective DOT-HAART studies have shown mixed results, and optimal target groups have yet to be defined. We performed a meta-analysis and systematic review to assess the effect of DOT-HAART on adherence and virologic and immunologic response.

METHODS

We performed a comprehensive search through August 2009 to identify peer-reviewed controlled studies that involved outpatient DOT-HAART among adults and reported at least 1 outcome assessed in this meta-analysis. Random-effects meta-analyses were performed; differences in effect on virologic suppression were examined using stratified meta-analyses and meta-regression on several study characteristics.

RESULTS

Seventeen studies met inclusion criteria. Compared with control groups, DOT-HAART recipients were more likely to achieve an undetectable viral load (random effects risk ratio 1.24, 95% confidence interval (CI): 1.08 to 1.41), a greater increase in CD4 cell count (random effects weighted mean difference 43 cells/microL, 95% CI: 12 to 74 cells/microL), and HAART adherence of > or =95% (random effects risk ratio 1.17, 95% CI: 1.03 to 1.32). Results varied with respect to virologic response. DOT-HAART did not have a significant effect on virologic suppression when restricted to randomized controlled studies. Post-treatment effect was not observed in a limited number of studies.

CONCLUSIONS

DOT-HAART had a significant effect on virologic, immunologic, and adherence outcomes, although its efficacy was not supported when restricting analysis to randomized controlled trials. DOT-HAART shows greatest treatment effect when targeting individuals with greater risk of nonadherence and when delivering the intervention that maximizes participant convenience and provides enhanced adherence support. Further investigation is needed to assess the postintervention effect and cost-effectiveness of DOT-HAART.

Community-based DOT-HAART accompaniment in an urban resource-poor setting

From December 2005 to April 2007, we enrolled 60 adults starting antiretroviral therapy (ART) in a health district of Lima, Peru to receive community-based accompaniment with supervised antiretroviral (CASA). Paid community health workers performed twice-daily home visits to directly observe ART and offered additional medical, social and economic support to CASA participants. We matched 60 controls from a neighboring district by age, CD4 and primary referral criteria (TB status, female, neither). Using validated instruments at baseline and 12 months (time of DOT-HAART completion) we measured depression, social support, quality of life, HIV-related stigma and self-efficacy. We compared 12 month clinical and psychosocial outcomes among CASA versus control groups. CASA participants experienced better clinical and psychosocial outcomes at 12 months, including proportion with virologic suppression, increase in social support and reduction in HIV-associated stigma.

Assessing the viorologic and adherence benefits of patient-selected HIV treatment partners in a resource-limited setting

OBJECTIVE

To determine the efficacy of patient-selected treatment partners on virologic and adherence outcomes during first-line antiretroviral therapy.

DESIGN

Randomized controlled trial. SETTING AND ANALYTICAL APPROACH: Between June 2006 and December 2007, 499 HIV-infected adults in Jos, Nigeria, were randomized to standard of care (SOC) or patient-selected treatment partner-assisted therapy (TPA). Each patient was followed for 48 weeks. Virologic outcomes, adherence to drug pick-up, CD4 cell counts, and mortality are reported.

RESULTS

At week 24, undetectable viral load was achieved by 61.7% of patients in the TPA arm versus 50.2% of those receiving SOC [odds ratio (OR) = 1.58, 95% CI: 1.11 to 2.26, P < 0.05]. There was no significant difference at week 48: 65.3% versus 59.4% for TPA and SOC, respectively (OR = 1.28, 95% CI: 0.89 to 1.84, P > 0.05). The TPA group had more than 3 times the odds of at least 95% drug pickup adherence through week 24 (OR = 3.06, 95% CI: 1.89 to 4.94, P < 0.01) and almost twice the odds through week 48 (OR = 1.95, 95% CI: 1.29 to 2.93, P < 0.01). At week 48, there were no significant differences in CD4 cell count increases (t = -0.09, df = 404, P > 0.05) or mortality (10.6% vs. 6.1%) between TPA vs. SOC, respectively. Residence-to-clinic distance was significantly associated with virologic and adherence outcomes.

CONCLUSIONS

Use of patient-selected treatment partners was associated with improved drug pickup adherence and initial virologic success but had no durable effect on attaining undetectable viral load.

Access to antiretroviral therapy for adults and children with HIV infection in developing countries: Horizons studies, 2002-2008

The Access-to-Treatment research initiative of the Population Council's Horizons program undertook 11 projects across Asia and sub-Saharan Africa from 2002 to 2008. The projects included a variety of cross-sectional exploratory studies, situation analyses, and longitudinal randomized, controlled intervention studies that examined service delivery, community awareness, health-seeking behaviors, adherence, cost, and other factors affecting treatment for adults and children infected with human immunodeficiency virus (HIV). This article summarizes the key findings and lessons learned from these projects, and examines cross-cutting issues such as stigma, quality of life, and sexual-risk behaviors among people living with HIV and acquired immunodeficiency syndrome on antiretroviral therapy. The article concludes with recommendations for evidence-based programming and future research around treatment for both children and adults.

Adherence to antiretroviral therapy: the more you look, the more you see

PURPOSE OF REVIEW

There is evolving understanding of adherence to antiretroviral therapy (ART) and the consequences of nonadherence. The present review aims to discuss recent research findings that illuminate lingering clinical questions or contribute to the contextual framework for future research.

RECENT FINDINGS

Although some patients can achieve undetectable viral load at moderate adherence levels, studies confirmed that achieving very high adherence optimizes virological and clinical outcomes. In computer modeling, earlier initiation of ART despite suboptimal adherence was associated with improved survival and quality-adjusted life years. Better adherence and virological outcomes occurred when ART was initiated during hospitalization versus outpatient setting, and when depressed patients were treated with selective serotonin reuptake inhibitors. Differential adherence to individual drugs in an antiretroviral regimen appears to be common. Preliminary data from randomized studies designed to evaluate patient-selected treatment partners showed no clear benefit on long-term viral suppression.

SUMMARY

Earlier initiation of ART may be desirable even in some patients with suboptimal adherence. Adherence should be reinforced during periods of viral suppression, maximum adherence should be targeted, and attention paid to differential adherence and treatment of depression.

Antiretroviral therapy adherence and retention in care in middle-income and low-income countries: current status of knowledge and research priorities

PURPOSE OF REVIEW

Adherence to combination antiretroviral therapy (cART) is one of the most important contributing factors to positive clinical outcomes in patients with HIV, and long-term retention of patients in low-income and middle-income countries is emerging as an important issue in rapidly expanding cART programs. This review presents recent developments in both treatment adherence and retention of patients in low-income and middle-income countries.

RECENT FINDINGS

Adherence is among the most modifiable variables in treatment, but there still is no 'gold standard' measurement. Best estimates demonstrate that adherence in resource-limited settings is equal or superior to that in resource-rich settings, possibly due to focused efforts on support groups and community acceptance of adherence behaviors. However, long-term data show that sustained efforts to ensure high cART adherence and evidence of intervention effects are critical, but that resource-intensive interventions are not warranted in settings where cART adherence is high. Furthermore, well conducted evaluation of culturally sensitive interventions to maximize pre-cART and post-cART initiation retention is badly needed in low-income and middle-income settings.

SUMMARY

Further research is needed to identify risk factors and to improve adherence and retention among children, adolescents, and adults through use of social networks or emerging technologies for patients at risk for poor adherence.

Directly observed antiretroviral therapy: a systematic review and meta-analysis of randomised clinical trials

BACKGROUND

Directly observed therapy has been recommended to improve adherence for patients with HIV infection who are on highly active antiretroviral therapy, but the benefit and cost-effectiveness of this approach has not been established conclusively. We did a systematic review and meta-analysis of randomised trials of directly observed versus self-administered antiretroviral treatment.

METHODS

We did duplicate searches of databases (from inception to July 27, 2009), searchable websites of major HIV conferences (up to July, 2009), and lay publications and websites (March-July, 2009) to identify randomised trials assessing directly observed therapy to promote adherence to antiretroviral therapy in adults. Our primary outcome was virological suppression at study completion. We calculated relative risks (95% CIs), and pooled estimates using a random-effects method.

FINDINGS

12 studies met our inclusion criteria; four of these were done in groups that were judged to be at high risk of poor adherence (drug users and homeless people). Ten studies reported on the primary outcome (n=1862 participants); we calculated a pooled relative risk of 1.04 (95% CI 0.91-1.20, p=0.55), and noted moderate heterogeneity between the studies (I(2)= 53.8%, 95% CI 0-75.7, p=0.0247) for directly observed versus self-administered treatment.

INTERPRETATION

Directly observed antiretroviral therapy seems to offer no benefit over self-administered treatment, which calls into question the use of such an approach to support adherence in the general patient population.

FUNDING

None.

Explaining adherence success in sub-Saharan Africa: an ethnographic study

BACKGROUND

Individuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). This number exceeds the levels of adherence observed in North America and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty. This paper offers an explanation and theoretical model of ART adherence success based on the results of an ethnographic study in three sub-Saharan African countries.

METHODS AND FINDINGS

Determinants of ART adherence for HIV-infected persons in sub-Saharan Africa were examined with ethnographic research methods. 414 in-person interviews were carried out with 252 persons taking ART, their treatment partners, and health care professionals at HIV treatment sites in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic activities were also conducted. Data were examined using category construction and interpretive approaches to analysis. Findings indicate that individuals taking ART routinely overcome economic obstacles to ART adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and "begging" transport funds, making "impossible choices" to allocate resources in favor of treatment, and "doing without." Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise.

CONCLUSION

Adherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities and thus preserving social capital in essential relationships.