Interventions to promote adherence to antiretroviral therapy in Africa: a network meta-analysis

Edward J Mills; Richard Lester; Kristian Thorlund; Maria Lorenzi; Katherine Muldoon; Steve Kanters; Sebastian Linnemayr; Robert Gross; Yvette Calderon; K Rivet Amico; Harsha Thirumurthy; Cynthia Pearson; Robert H Remien; Lawrence Mbuagbaw; Lehana Thabane; Michael H Chung; Ira B Wilson; Albert Liu; Olalekan A Uthman; Jane Simoni; David Bangsberg; Sanni Yaya; Till Bärnighausen; Nathan Ford; Jean B Nachega

doi:10.1016/S2352-3018(14)00003-4

Interventions to promote adherence to antiretroviral therapy in Africa: a network meta-analysis

Lancet HIV. 2014 Dec;1(3):e104-11. doi: 10.1016/S2352-3018(14)00003-4. Epub 2014 Nov 24.

Authors

Edward J Mills¹, Richard Lester², Kristian Thorlund³, Maria Lorenzi⁴, Katherine Muldoon², Steve Kanters², Sebastian Linnemayr⁵, Robert Gross⁶, Yvette Calderon⁷, K Rivet Amico⁸, Harsha Thirumurthy⁹, Cynthia Pearson¹⁰, Robert H Remien¹¹, Lawrence Mbuagbaw¹², Lehana Thabane¹², Michael H Chung¹³, Ira B Wilson¹⁴, Albert Liu¹⁵, Olalekan A Uthman¹⁶, Jane Simoni¹⁷, David Bangsberg¹⁸, Sanni Yaya¹⁹, Till Bärnighausen²⁰, Nathan Ford²¹, Jean B Nachega²²

Affiliations

¹ Stanford Prevention Research Center, Stanford University, Stanford, CA, USA. Electronic address: [email protected].
² School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
³ Stanford Prevention Research Center, Stanford University, Stanford, CA, USA; Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
⁴ Stanford Prevention Research Center, Stanford University, Stanford, CA, USA.
⁵ RAND Corp, Los Angeles, CA, USA.
⁶ University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
⁷ Department of Emergency Medicine, Albert Einstein University, New York, NY, USA.
⁸ Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA.
⁹ Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA.
¹⁰ School of Social Work, University of Washington, Seattle, WA, USA.
¹¹ HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY, USA.
¹² Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
¹³ Department of Global Health, School of Medicine and Public Health, University of Washington, Seattle, WA, USA.
¹⁴ Department of Health Services, Policy & Practice, Brown University, Providence, RI, USA.
¹⁵ Center for AIDS Research, UCSF, San Francisco, CA, USA.
¹⁶ Centre for Applied Health Research & Delivery, Warwick University, Coventry, UK.
¹⁷ Department of Psychology, University of Washington, Seattle, WA, USA.
¹⁸ Harvard School of Public Health, Harvard, Boston, MA, USA.
¹⁹ Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.
²⁰ Harvard School of Public Health, Harvard, Boston, MA, USA; Wellcome Trust Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa.
²¹ Department of HIV/AIDS, WHO, Geneva, Switzerland.
²² Center for Infectious Diseases, Stellenbosch University, Cape Town, Western Cape, South Africa.

Abstract

Background: Adherence to antiretroviral therapy (ART) is necessary for the improvement of the health of patients and for public health. We sought to determine the comparative effectiveness of different interventions for improving ART adherence in HIV-infected people living in Africa.

Methods: We searched for randomised trials of interventions to promote antiretroviral adherence within adults in Africa. We searched AMED, CINAHL, Embase, Medline (via PubMed), and ClinicalTrials.gov from inception to Oct 31, 2014, with the terms "HIV", "ART", "adherence", and "Africa". We created a network of the interventions by pooling the published and individual patients' data for comparable treatments and comparing them across the individual interventions with Bayesian network meta-analyses. The primary outcome was adherence defined as the proportion of patients meeting trial defined criteria; the secondary endpoint was viral suppression.

Findings: We obtained data for 14 randomised controlled trials, with 7110 patients. Interventions included daily and weekly short message service (SMS; text message) messaging, calendars, peer supporters, alarms, counselling, and basic and enhanced standard of care (SOC). Compared with SOC, we found distinguishable improvement in self-reported adherence with enhanced SOC (odds ratio [OR] 1·46, 95% credibility interval [CrI] 1·06-1·98), weekly SMS messages (1·65, 1·25-2·18), counselling and SMS combined (2·07, 1·22-3·53), and treatment supporters (1·83, 1·36-2·45). We found no compelling evidence for the remaining interventions. Results were similar when using viral suppression as an outcome, although the network contained less evidence than that for adherence. Treatment supporters with enhanced SOC (1·46, 1·09-1·97) and weekly SMS messages (1·55, 1·01-2·38) were significantly better than basic SOC.

Interpretation: Several recommendations for improving adherence are unsupported by the available evidence. These findings can inform future intervention choices for improving ART adherence in low-income settings.

Funding: None.

Abstract

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