Prospective, randomized, two-arm controlled study to evaluate two interventions to improve adherence to antiretroviral therapy in Spain

Evaluation of a peer intervention project in the hospital setting to improve the health-related quality of life of recently diagnosed people with HIV infection

PURPOSE

This study aims to assess the impact of a peer intervention programme in the hospital setting to improve the health-related quality of life (HRQoL) of people recently diagnosed with HIV infection.

METHODS

A quasi-experimental single-group study with pre- and post-measurements was conducted. The peer intervention programme consisted of four sessions that took place at the following times: (1) the day of diagnosis, (2) the day when the results of the analyses were collected and ART (antiretroviral therapy) began, (3) one month after the start of ART, and (4) four months after the start of ART. The dependent variables were HRQoL and several of its psychological predictors. Change in the dependent variables was analysed through repeated measures, variance analysis and covariance analysis. Forty-three people with HIV participated in the intervention (40 men, mean age = 39.14).

RESULTS

A significant positive evolution was found in all the predictors of HRQoL, except avoidant coping (p < .05). A positive evolution was also found in all HRQoL dimensions (p < .05). There was a significant increase in CD4 cells/mm3 lymphocytes (p < .0001) and in the CD4/CD8 ratio (p < .001). The positive differential scores in the psychological health and social relationship dimensions influenced the increase in CD4 cells/mm3 lymphocytes (p = .012, p = .13). The increase in the social relations dimension score and overall health perception influenced the recovery of the CD4/CD8 ratio (p = .044; p = .068).

CONCLUSIONS

Peer intervention improved the HRQoL of people recently diagnosed with HIV, and enhanced psychological health and social relationships covariate with their immunological recovery. This study represents an essential advance in evaluating peer intervention programmes for positive prevention.

The effectiveness and sustainability of peer support interventions for persons living with HIV: a realist synthesis

BACKGROUND

Peer support is an important supplement to medical resources for persons living with HIV (PLHIV). However, previous studies have shown mixed results about intervention effects. It is necessary to explain the mechanism of peer support interventions' effectiveness and sustainability to help design more valid peer support interventions.

OBJECTIVE

To identify and explain the mechanisms that drive the effectiveness and maintain the sustainability of peer support interventions.

METHODS

A preliminary theoretical framework was developed through a scoping review of the grey literature and international project frameworks in five professional websites. We then refined the framework by systematically searching evidence in databases including PubMed, EMBASE, Web of Science, ProQuest, CINAHL, CNKI and Wanfang. Qualitative methods were used to generate codes and themes relating to the studies' context, mechanisms and outcomes. We checked chains of inference (connections) across extracted data and themes through an iterative process.

RESULTS

A total of 6345 articles were identified, and 52 articles were retained for final synthesis. The refined theoretical framework presents five areas of peer support, including informational support, instrumental support, emotional support, affiliational support and appraisal support; five types of outcomes that peer support can improve for PLHIV, including physiological outcomes, psychological outcomes, behavioural outcomes, cognitive outcomes and social outcomes; the effectiveness mechanism coding system from peer volunteers and the relationship between peer volunteers and PLHIV; and the sustainability mechanism coding system in terms of peer volunteers, PLHIV and study context.

CONCLUSIONS

Given that peer support has huge potential human resources, that is, all the qualified PLHIV, irreplaceable advantages in dealing with barriers to HIV-related discrimination and potential comprehensive benefits for PLHIV, it is necessary to develop and organise more peer support projects for PLHIV. Our study highlights that the expansion of peer support projects should be based on their effectiveness and sustainability.

PROSPERO REGISTRATION NUMBER

CRD42022339079.

What is the volume, diversity and nature of recent, robust evidence for the use of peer support in health and social care? An evidence and gap map

Background

Peer support interventions involve people drawing on shared personal experience to help one another improve their physical or mental health, or reduce social isolation. If effective, they may also lessen the demand on health and social care services, reducing costs. However, the design and delivery of peer support varies greatly, from the targeted problem or need, the setting and mode of delivery, to the number and content of sessions. Robust evidence is essential for policymakers commissioning peer support and practitioners delivering services in health care and community settings. This map draws together evidence on different types of peer support to support the design and delivery of interventions.

Objectives

The aim of this map was to provide an overview of the volume, diversity and nature of recent, high quality evidence on the effectiveness and cost-effectiveness of the use of peer support in health and social care.

Search Methods

We searched MEDLINE, seven further bibliographic databases, and Epistemonikos for systematic reviews (in October 2020), randomised controlled trials (in March 2021) and economic evaluations (in May 2021) on the effectiveness of peer support interventions in health and social care. We also conducted searches of Google Scholar, two trial registers, PROSPERO, and completed citation chasing on included studies.

Selection Criteria

Systematic reviews, randomised controlled trials and economic evaluations were included in the map. Included studies focused on adult populations with a defined health or social care need, were conducted in high-income countries, and published since 2015. Any measure of effectiveness was included, as was any form of peer support providing the peer had shared experience with the participant and a formalised role.

Data Collection and Analysis

Data were extracted on the type of peer support intervention and outcomes assessed in included studies. Standardised tools were used to assess study quality for all studies: assessing the methodological quality of systematic reviews 2 for systematic reviews; Cochrane risk of bias tool for randomised controlled trials; and consensus health economic criteria list for economic evaluations.

Main Results

We included 91 studies: 32 systematic reviews; 52 randomised controlled trials; and 7 economic evaluations. Whilst most included systematic reviews and economic evaluations were assessed to be of low or medium quality, the majority of randomised controlled trials were of higher quality. There were concentrations of evidence relating to different types of peer support, including education, psychological support, self-care/self-management and social support. Populations with long-term health conditions were most commonly studied. The majority of studies measured health-related indicators as outcomes; few studies assessed cost-effectiveness. Studies were unevenly distributed geographically, with most being conducted in the USA. Several gaps were evident regarding the delivery of peer support, particularly the integration of peers and professionals in delivering support and interventions of longer duration.

Authors' Conclusions

Although there is evidence available to inform the commissioning and delivery of peer support in health and social care, there are also clear gaps that need to be addressed to further support provision, particularly regarding cost-effectiveness. The effectiveness of peer support in different countries, with varying health and social care systems, is a priority for future research, as is the integration of peers with professionals in delivering peer support.

The effectiveness of peer-support for people living with HIV: A systematic review and meta-analysis

BACKGROUND

The practice of involving people living with HIV in the development and provision of healthcare has gained increasing traction. Peer-support for people living with HIV is assistance and encouragement by an individual considered equal, in taking an active role in self-management of their chronic health condition. The objective of this systematic review was to assess the effects of peer-support for people living with HIV.

METHODS

We conducted a systematic review in accordance with international guidelines. Following systematic searches of eight databases until May 2020, two reviewers performed independent screening of studies according to preset inclusion criteria. We conducted risk of bias assessments and meta-analyses of the available evidence in randomised controlled trials (RCTs). The certainty of the evidence for each primary outcome was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

After screening 219 full texts we included 20 RCTs comprising 7605 participants at baseline from nine different countries. The studies generally had low risk of bias. Main outcomes with high certainty of evidence showed modest, but superior retention in care (Risk Ratio [RR] 1.07; Confidence Interval [CI] 95% 1.02-1.12 at 12 months follow-up), antiretroviral therapy (ART) adherence (RR 1.06; CI 95% 1.01-1.10 at 3 months follow-up), and viral suppression (Odds Ratio up to 6.24; CI 95% 1.28-30.5 at 6 months follow-up) for peer-support participants. The results showed that the current state of evidence for most other main outcomes (ART initiation, CD4 cell count, quality of life, mental health) was promising, but too uncertain for firm conclusions.

CONCLUSIONS

Overall, peer-support with routine medical care is superior to routine clinic follow-up in improving outcomes for people living with HIV. It is a feasible and effective approach for linking and retaining people living with HIV to HIV care, which can help shoulder existing services.

TRIAL REGISTRATION

CRD42020173433.

Antiretroviral Therapy (ART)-related Knowledge Seeking among People Living with HIV (PLHIV) in China: Role of Information & Communication Technology (ICT)

This paper investigated the use of information communication technology (ICT) to seek antiretroviral therapy (ART)-related knowledge among people living with HIV (PLHIV) taking antiretroviral treatment in Guangxi, China. A total 1902 participants who undertook ART and had used ICT were recruited from 12 sites with the highest cumulative HIV incidence. A questionnaire survey was used to collect data on the participants’ sociodemographic characteristics, clinical outcomes, infections in the family and comorbidity, access to healthcare resources, ICT using behavior in HIV management, and ART-related knowledge. The results showed that 15% of the participants had searched HIV-related information online, fewer participants had contacted healthcare providers via computer (1.6%) or text messaging (11.9%), and only 7.7% of the participants had contacted other PLHIV using ICT. Education had a positive impact on the knowledge level of all three categories of ART-related knowledge. Participants with better medication and mechanisms knowledge were more likely to search HIV-related information online and less likely to contact healthcare providers using text messages. Findings of this study suggested that ICT was used as an effective approach to acquire some type of ART-related knowledge. ICT was underutilized in health communication among the PLHIV in this study due to low education level and insufficient eHealth literacy. Future intervention programs should address the customization of the communication tools and focus on improving the education level and eHealth literacy of the PLHIV to better promote ICT as an efficient platform for ART-related knowledge seeking.

Peer-led Self-management Interventions and Adherence to Antiretroviral Therapy Among People Living with HIV: A Systematic Review

Adherence to antiretroviral therapy (ART) is essential to reduce morbidity and mortality among people living with HIV (PLWH). However, adherence remains suboptimal, and PLWH may benefit from more self-management support to address the complexities of chronic illness. Our objective was to identify the impact of peer-led self-management interventions on adherence and patient-reported outcomes (PROs) among PLWH. We searched MEDLINE, PubMed, Embase, PsycINFO, and CINAHL for English language publications from 1996 to March 2018, and included controlled intervention studies. Additional articles were handsearched, risk of bias assessed, and narrative syntheses outlined. Thirteen studies met inclusion criteria. Findings demonstrate unclear effectiveness for peer-led self-management interventions improving ART adherence; however evidence was limited with only seven studies measuring this outcome and some risk of bias. Many PROs were measured, with limited consistent findings. Future research is needed to strengthen the evidence regarding effects of peer-led self-management interventions on adherence and PROs among PLWH.

Factors Influencing the Successful Implementation of HIV Linkage and Retention Interventions in Healthcare Agencies Across New York State

As part of the System Linkages and Access to Care Initiative, 12 HIV service delivery organizations in New York implemented one of the following three interventions to improve linkage to and retention in HIV care at their site: Peer Support, Appointment Procedures, and Anti-Retroviral Treatment and Access to Services. Aggregate process measure data describing intervention delivery, in conjunction with qualitative findings to help explain barriers and facilitators to achieving full implementation were examined. Process data from the interventions showed shortcomings in the percentage of eligible patients who went on to be enrolled, and the number of enrollees who ultimately received the components of the interventions. Factors identified in qualitative interviews that facilitated implementation and intervention delivery included: concerted buy-in and coordination of staff, building upon existing infrastructure including ensuring sufficient staff capacity, and allowing adaptability of certain parts of the intervention to better fit patient needs and clinical settings.

Patient-nominated supporters as facilitators for engagement in HIV care in a referral hospital in Peru: A retrospective cohort study

Patient-nominated supporters can potentially improve the continuum of HIV care. We retrospectively determined factors associated with having a patient-nominated supporter among people living with HIV (PLWH), and its association with retention in care and viral suppression. We analysed registries of adults evaluated by social workers (n = 1345) at a referral hospital in Peru between 2011–2014. Nondisclosure of HIV status was associated with lacking supporters (aPR: 5.41, 95% CI: 3.83–7.64). Retention in care was 76.4% and 34.2% after one and two years of enrolment, respectively. PLWH with supporters were more likely to be retained in care after two years (aRR = 1.36, 95% CI: 1.02–1.81), but not after one year (aRR = 1.10, 95% CI: 0.98–1.23) compared to PLWH without supporters. Having supporters who were parents or friends was associated with an increased probability of being retained in care after one and two years of enrolment. Viral suppression after one year of enrolment was 58.7%. Having a supporter was not associated with viral suppression (aRR = 1.18, 95% CI: 0.99–1.41), but PLWH with supporters were more likely to have viral load measurements (p = 0.005). Patient-nominated supporters appear beneficial for engagement in HIV care; these benefits may be related to the nature of their relationship with PLWH.

Do peer support groups have an effect on medication adherence? A study among people living with HIV/AIDS in Enugu State, Nigeria

Background:

The health benefits of antiretroviral treatment greatly depend on the extent to which people living with HIV/AIDS adhere to the prescribed daily dosing regimens. Peer support groups are expected to have a high impact on adherence to medication among people living with HIV/AIDS.

Objectives:

This study was designed to determine factors affecting adherence to medication among people living with HIV/AIDS in peer support and non-support groups attending antiretroviral clinics in Enugu State, Nigeria.

Method:

This was a cross-sectional, comparative study using qualitative and quantitative instruments among 840 people living with HIV/AIDS attending antiretroviral clinics in Enugu, Nigeria. Quantitative data was analysed using IBM SPSS version 22. A Chi-square test of statistical significance, a student t-test and multivariate analysis using binary logistic regression were used in the analysis. Manual content analysis was done for the qualitative data.

Results:

The mean age of respondents was comparable in both study groups: support group 38.5±9.6; and non-support group 38.5±10.1. A significantly higher proportion of respondents in the support group (91.9%) achieved good adherence compared with those in the non-support group (87.1%). A good medication adherence self-rating was a predictor of adherence in both study groups: support group (AOR 5.8, 95% CI: 2.7–12.2, p=<0.001) and non-support group (AOR 0.2, 95% CI: 0.1–0.4, p=<0.001).

Conclusion:

The peer-based intervention is a viable and effective tool for maintaining optimal adherence among people living with HIV/AIDS in resource-limited settings; hence, research should concentrate on interventions that do not focus on individuals alone, but rather on those that strengthen the capacity of groups to collectively participate in HIV programmes.

Social and behavioral interventions for improving quality of life of HIV infected people receiving antiretroviral therapy: a systematic review and meta-analysis

BACKGROUND

Improvement in quality of life is crucial for HIV infected people. Social and behavioral interventions have been implemented in different contexts to improve the quality of life among HIV infected people. This review appraises the evidence for available interventions that focused on quality of life of HIV infected people receiving antiretroviral therapy (ART).

METHODS

We searched electronic databases for randomized controlled trials of interventions to improve the quality of life of HIV infected people receiving ART. We searched PUBMED and the Cochrane Centre Register of Controlled Trials (CENTRAL) with the terms "social", "behavioral", "educational", "quality of life", "HIV", and "RCT". Searches were conducted for articles published from 1980 to December 16, 2015. Standardized data abstraction methods and searching steps were applied.

RESULTS

Twenty-eight studies reported the impact of social or behavioral interventions in quality of life among HIV infected people, of which 15 were conducted in United States of America. A total of 4136 participants were enrolled. Of the 28 studies, four studies included females, two studies included males and remaining studies excluded both males and females. The overall reported methodological quality of the studies was subject to a high risk of bias and the study criteria were unclear in most studies. Twenty-one studies reported a significant intervention effect on at least one quality of life domain. Meta-analyses showed significant improvement in general health, mental health, physical function and environment domains of quality of life among intervention groups. However, the expected impact of the intervention was low to moderate because the rigorousness of the studies was low, information was limited, the sample sizes were small and other the quality of the study designs were poor.

CONCLUSIONS

Although the available evidence suggests that existing social and behavioral interventions can improve some quality of life domains, the quality of evidence was insufficient to support the notion that these interventions can improve the overall quality of life of HIV infected people receiving ART. Well-designed and rigorous randomized controlled trials with high methodological quality are required.

Use of peers to improve adherence to antiretroviral therapy: a global network meta-analysis

INTRODUCTION

It is unclear whether using peers can improve adherence to antiretroviral therapy (ART). To construct the World Health Organization's global guidance on adherence interventions, we conducted a systematic review and network meta-analysis to determine the effectiveness of using peers for achieving adequate adherence and viral suppression.

METHODS

We searched for randomized clinical trials of peer-based interventions to promote adherence to ART in HIV populations. We searched six electronic databases from inception to July 2015 and major conference abstracts within the last three years. We examined the outcomes of adherence and viral suppression among trials done worldwide and those specific to low- and middle-income countries (LMIC) using pairwise and network meta-analyses.

RESULTS AND DISCUSSION

Twenty-two trials met the inclusion criteria. We found similar results between pairwise and network meta-analyses, and between the global and LMIC settings. Peer supporter+Telephone was superior in improving adherence than standard-of-care in both the global network (odds-ratio [OR]=4.79, 95% credible intervals [CrI]: 1.02, 23.57) and the LMIC settings (OR=4.83, 95% CrI: 1.88, 13.55). Peer support alone, however, did not lead to improvement in ART adherence in both settings. For viral suppression, we found no difference of effects among interventions due to limited trials.

CONCLUSIONS

Our analysis showed that peer support leads to modest improvement in adherence. These modest effects may be due to the fact that in many settings, particularly in LMICs, programmes already include peer supporters, adherence clubs and family disclosures for treatment support. Rather than introducing new interventions, a focus on improving the quality in the delivery of existing services may be a more practical and effective way to improve adherence to ART.

Interventions to improve adherence to antiretroviral therapy: a systematic review and network meta-analysis

BACKGROUND

High adherence to antiretroviral therapy is crucial to the success of HIV treatment. We evaluated comparative effectiveness of adherence interventions with the aim of informing the WHO's global guidance on interventions to increase adherence.

METHODS

For this systematic review and network meta-analysis, we searched for randomised controlled trials of interventions that aimed to improve adherence to antiretroviral therapy regimens in populations with HIV. We searched Cochrane Central Register of Controlled Trials, Embase, and MEDLINE for reports published up to July 16, 2015, and searched major conference abstracts from Jan 1, 2013, to July 16, 2015. We extracted data from eligible studies for study characteristics, interventions, patients' characteristics at baseline, and outcomes for the study populations of interest. We used network meta-analyses to compare adherence and viral suppression for all study settings (global network) and for studies in low-income and middle-income countries only (LMIC network).

FINDINGS

We obtained data from 85 trials with 16 271 participants. Short message service (SMS; text message) interventions were superior to standard of care in improving adherence in both the global network (odds ratio [OR] 1·48, 95% credible interval [CrI] 1·00-2·16) and in the LMIC network (1·49, 1·04-2·09). Multiple interventions showed generally superior adherence to single interventions, indicating additive effects. For viral suppression, only cognitive behavioural therapy (1·46, 1·05-2·12) and supporter interventions (1·28, 1·01-1·71) were superior to standard of care in the global network; none of the interventions improved viral response in the LMIC network. For the global network, the time discrepancy (whether the study outcome was measured during or after intervention was withdrawn) was an effect modifier for both adherence to antiretroviral therapy (coefficient estimate -0·43, 95% CrI -0·75 to -0·11) and viral suppression (-0·48; -0·84 to -0·12), suggesting that the effects of interventions wane over time.

INTERPRETATION

Several interventions can improve adherence and viral suppression; generally, their estimated effects were modest and waned over time.

FUNDING

WHO.

Cost analysis of pharmaceutical care provided to HIV-infected patients: an ambispective controlled study

BACKGROUND

Studies have shown that pharmaceutical care can result in favorable clinical outcomes in human immunodeficiency virus (HIV)-infected patients, however, few studies have assessed the economic impact. The objective of this study was to evaluate the clinical and economic impact of pharmaceutical care of HIV-infected patients.

METHODS

A controlled ambispective study was conducted in Brazil from January 2009 to June 2012. Patients were allocated to either intervention or control group. The control group was followed according to standard care while the intervention group was also followed by a pharmacist at each physician appointment for one year. Effectiveness outcomes included CD4+ count, viral load, absence of co-infections and optimal immune response, and economic outcomes included expenses of physician and pharmaceutical appointments, laboratory tests, procedures, and hospitalizations, at six months and one year.

RESULTS

Intervention and control groups included 51 patients each. We observed significant decreases in total pharmacotherapy problems during the study. At six months, the intervention group contained higher percentages of patients without co-infections and of patients with CD4+ >500 cells/mm(3). None of the differences between intervention and control group considering clinical outcomes and costs were statistically significant. However, at one year, the intervention group showed higher percentage of better clinical outcomes and generated lower spending (not to procedures). An additional health care system daily investment of US$1.45, 1.09, 2.13, 4.35, 1.09, and 0.87 would be required for each additional outcome of viral load <50 copies/ml, absence of co-infection, CD4+ >200, 350, and 500 cells/mm(3), and optimal immune response, respectively.

CONCLUSION

This work demonstrated that pharmaceutical care of HIV-infected patients, for a one-year period, was able to decrease the number of pharmacotherapy problems. However, the clinical outcomes and the costs did not have statistical difference but showed higher percentage of better clinical outcomes and lower costs for some items.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

Adherence-enhancing interventions for highly active antiretroviral therapy in HIV-infected patients - a systematic review

OBJECTIVES

The objective of this systematic review was to evaluate the effectiveness of adherence-enhancing interventions for highly active antiretroviral therapy (HAART) in HIV-infected patients in developed countries.

METHODS

A systematic literature search was performed (January 2001 to May 2012) in EMBASE, including MEDLINE records, CENTRAL and PsycInfo. Trials meeting the following predefined inclusion criteria were included: adult patients with an HIV infection treated with HAART, an intervention to enhance patient adherence, adherence as the outcome, clinical outcomes, randomized controlled trial (RCT), article written in English or German, patient enrolment after 2001, and trial conducted in World Health Organization (WHO) stratum A. Selection was performed by two reviewers independently. All relevant data on patient characteristics, interventions, adherence measures and results were extracted in standardized tables. The methodological trial quality was evaluated by two reviewers independently. All discrepancies were discussed until a consensus was reached. A meta-analysis could not be performed because of the heterogeneity of trials.

RESULTS

In total, 21 trials fulfilled all inclusion criteria. Of 21 trials, only one that examined motivational interviewing for alcohol-dependent patients showed statistically significant results for adherence rates and viral load in favour of the intervention. One trial showed a statistically significant clinical effect of the intervention; however, inconsistent results were presented for adherence depending on the underlying adherence definition. The results of the remaining 19 trials were not statistically significant or were conflicting for adherence and/or clinical outcomes. However, the methodological trial quality was low.

CONCLUSIONS

It is not possible to definitively assess the effectiveness of adherence-enhancing interventions. However, it appears that most adherence interventions have no effect.

Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel

DESCRIPTION

After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). Adherence to ART is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV.

METHODS

A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation.

RECOMMENDATIONS

Recommendations are provided for monitoring entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.