SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
February, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Adherence can be defined as the extent to which patients follow the instructions they are given for prescribed treatments. Highly active antiretroviral therapy (HAART) has demonstrated remarkable success in reducing morbidity, mortality, and healthcare costs for HIV-positive people. The lifesaving benefits of HAART are not achieved if patients do not take them as prescribed. Behavioral interventions are intended to assist patients with this task.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Highly active antiretroviral therapy (HAART) has demonstrated remarkable success in inhibiting HIV viral replication and reducing morbidity, mortality, and overall healthcare costs for HIV-positive people. Without strict attention to dosing schedules and dietary restrictions, the effectiveness of HAART is severely compromised. Non-adherence to HAART is very common. Potential causes include problems with the regimen (e.g. adverse effects), poor instructions, poor provider-patient relationships, poor memory, and patients’ disagreement with the need for treatment or inability to pay for it. Given the multifaceted dimensions of this phenomenon, there is a wide array of possible interventions. Behavioral interventions represent a key strategy for addressing non-adherence to HAART.
| Review objectives: To summarise literature on the effects of patient support strategies and education for improving adherence to highly active antiretroviral therapy (HAART) in people living with HIV/AIDS. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials evaluating behavioral interventions to improve adherence to HAART |
19 randomised trials of diverse behavioral interventions: 1-on-1 counselling (10 trials), and group format (3). Components of the intervention were: didactic information on HAART (15 studies); interactive discussions addressing cognitions, motivations, and expectations (15); Behavioral strategies (16), such as cue dosing or cognitive-behavior therapy; external reminders such as pagers (5). Many interventions included more than one of these components. |
| Participants | Adults infected with HIV and receiving HAART |
7 studies restricted inclusion to patients exhibiting some marker of risk for non-adherence, such as poor baseline adherence or detectable viral load. Participants in the US studies were mostly racial/ethnic minorities. |
| Settings | Any setting |
Most studies (16) studies took place in outpatient HIV primary care clinics in high-income countries: United States (14), Spain (2), France (2) and Switzerland (1). |
| Outcomes | Any measure of adherence or HIV-1 RNA viral load (a measure of successful HAART) |
Adherence was measured in 18 studies. Data on undetectable viral load were available from 14 studies. |
| Date of most recent search: September 2005 in Simoni 2006, updated October 2009 in Simoni 2010 | ||
| Limitations: This is a well-conducted systematic review with only minor limitations. | ||
Simoni JM, Pearson CR, Pantalone DW, et al. Efficacy of interventions in improving highly active antiretroviral therapy adherence and HIV-1 RNA viral load. A meta-analytic review of randomized controlled trials. J Acquir Immune Defic Syndr 2006; 43(Suppl 1):S23-35.
Simoni JM. Antiretroviral adherence interventions: translating research findings to the real world clinic. Curr HIV/AIDS Rep 2010; 7:44-51.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
This review found 19 studies conducted in high-income countries, mostly in primary care HIV clinics. Studies evaluated behavioral interventions consisting of one or more of the following components: didactic information, interactive discussion, behavioral therapy, and reminders.
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Behavioral interventions for patients receiving HAART |
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People Adults infected with HIV and receiving highly active antiretroviral therapy (HAART) Settings Any setting Intervention Behavioral interventions Comparison Routine care or less intense behavioral interventions |
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Outcomes |
Absolute effects |
Relative effect (95% CI) |
Number of (studies) |
Certainty of the evidence (GRADE) |
Comments |
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Without a behavioral intervention |
With a behavioral intervention
Difference (Margin of error) |
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Adherence to HAART (>95%) |
50 per 100 |
60 per 100 (54 to 66) |
1.5 (1.16 to 1.94) |
1633 (18 studies) |
Moderate |
An update of the review including 10 additional randomised trials, found 9/10 beneficial |
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|
Viral load |
55 per 100 |
60 per 100 (55 to 66) |
1.25 (0.99 to 1.59) |
1247 (14 studies) |
Low |
An update of the review including 8 additional randomised trials, found mixed results for viral load |
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Patient outcomes |
No data were reported for this outcome. |
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Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
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All studies were conducted in high-income countries. The update of the review includes 3 studies in Brazil, China, and Mozambique, with mixed results.
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There are several ways in which the effects of interventions to improve adherence in high-income countries and low-income countries might differ, for instance cultural differences or availability of technologies. In some regions, especially in sub-Saharan Africa, HAART programs have started recently and attrition is a major problem. |
| EQUITY | |
| The included studies did not address equity issues. |
There might be differential effects of behavioral interventions on HAART adherence according to gender, education, religion, socioeconomic status, and racial or ethnic factors. |
| ECONOMIC CONSIDERATIONS | |
| None of the included studies assessed costs associated with behavioral interventions for improving adherence to HAART. |
Effective treatment of HIV is highly cost-effective. However, some behavioral interventions may be very expensive, especially when substantial human resources are required. This may pose a burden in low-income countries in addition to the already costly provision of HAART. |
| MONITORING & EVALUATION | |
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Adherence was measured by self-report or other unreliable methods in some studies.
This review was not able to determine which components of combined interventions are the ones that increase adherence.
There was little information about costs and adverse effects in the included studies.
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Measuring adherence is a complex task and frequently used methods such as self-report may lack both sensitivity and specificity. Future studies should use objective measures to provide a more accurate measure of true adherence, although these are more expensive. Future research should investigate which components of behavioral interventions improve adherence. Interventions to increase adherence consume resources and attempts to increase adherence can have adverse effects, such as loss of privacy and autonomy, and increased adverse effects of treatments. Adverse effects and costs should be monitored, as well as adherence.
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods |
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Mills EJ, Lester R, Thorlund K, et al. Interventions to promote adherence to antiretroviral therapy in Africa: a network meta-analysis. Lancet HIV 2014; 1(3):e104-11.
Haynes RB, Ackloo E, Sahota N, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev 2008; (2):CD000011.
Manias E, Williams A. Medication adherence in people of culturally and linguistically diverse back-grounds: a meta-analysis. Ann Pharmacother 2010; 44:964-82.
Hart JE, Jeon CY, Ivers LC, et al. Effect of directly observed therapy for highly active antiretroviral therapy on virologic, immunologic, and adherence outcomes: a meta-analysis and systematic review. J Acquir Immune Defic Syndr 2010; 54:167-79.
Mills EJ, Nachega JB, Buchan I, et al. Adherence to antiretroviral therapy in sub-Saharan Africa and North America: a meta-analysis. JAMA 2006 9;296:679-90.
Reisner MSL, Mimiaga MJ, Skeer MM, et al. A review of HIV antiretroviral adherence and intervention studies among HIV-infected youth. Top HIV Med 2009; 17:14-25.
Malta M, Magnanini MMF, Strathdee SA, et al. Adherence to antiretroviral therapy among HIV-infected drug users: a meta-analysis. AIDS Behav 2010; 14:731-47.
Wise J, Operario D. Use of electronic reminder devices to improve adherence to antiretroviral
therapy: a systematic review. AIDS Patient Care STDS 2008; 22:495-504.
Gabriel Rada. Unit for Health Policy and Systems Research, Faculty of Medicine, Pontificia Universidad
Católica de Chile.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Jane Simoni and Airton Stein.
Simoni JM. Antiretroviral adherence interventions: translating research findings to the real world clinic. Curr HIV/AIDS Rep 2010; 7:44-51.
Rada G. What are the effects of behavioral interventions to improve adherence to antiretroviral therapy? A SUPPORT Summary of a systematic review. February 2017. www.supportsummaries.org
Keywords
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care
Medication adherence, medication compliance, medication non-compliance,
medication non-adherence, patient compliance, treatment refusal.
