Abstract
BackgroundOptimal adherence to highly active antiretroviral therapy (HAART) is required to promote viral suppression and to prevent disease progression and mortality. Forcibly displaced and conflict-affected populations may face challenges succeeding on HAART. We performed a systematic review of the literature on adherence to HAART and treatment outcomes in these groups, including refugees and internally-displaced persons (IDPs), assessed the quality of the evidence and suggest a future research program.MethodsMedline, Embase, and Global Health databases for 1995–2011 were searched using the Ovid platform. A backward citation review of subsequent work that had cited the Ovid results was performed using the Web of Science database. ReliefWeb and Médecins Sans Frontières (MSF) websites were searched for additional grey literature.Results and conclusionWe screened 297 records and identified 17 reports covering 15 quantitative and two qualitative studies from 13 countries. Three-quarters (11/15) of the quantitative studies were retrospective studies based on chart review; five studies included <100 clients. Adherence or treatment outcomes were reported in resettled refugees, conflict-affected persons, internally-displaced persons (IDPs), and combinations of refugees, IDPs and other foreign-born persons. The reviewed reports showed promise for conflict-affected and forcibly-displaced populations; the range of optimal adherence prevalence reported was 87–99.5%. Treatment outcomes, measured using virological, immunological and mortality estimates, were good in relation to non-affected groups. Given the diversity of settings where forcibly-displaced and conflict-affected persons access ART, further studies on adherence and treatment outcomes are needed to support scale-up and provide evidence-based justifications for inclusion of these vulnerable groups in national treatment plans. Future studies and program evaluations should focus on systematic monitoring of adherence and treatment interruptions by using facility-based pharmacy records, understanding threats to optimal adherence and timely linkage to care throughout the displacement cycle, and testing interventions designed to support adherence and treatment outcomes in these settings.
Highlights
It is widely accepted that for Human immunodeficiency virus (HIV)-positive persons on highly active antiretroviral therapy (HAART), high levels of adherence to treatment regimens are essential for promoting viral suppression and preventing drug resistance
A check for sources that may have been posted online but omitted from health science databases was made by searching ReliefWeb and Médecins Sans Frontières (MSF) websites and three experts were consulted for additional sources
This study reported that community-based volunteers and health workers were effective in supporting adherence and the formation of social support groups, while social networks assisted in overcoming challenges that were independently related to displacement and stigma
Summary
It is widely accepted that for HIV-positive persons on highly active antiretroviral therapy (HAART), high levels of adherence to treatment regimens are essential for promoting viral suppression and preventing drug resistance. Conflict-affected and forcibly displaced populations such as refugees and internally-displaced persons (IDPs) may face unique challenges in sustaining good adherence to HAART and treatment outcomes [1,2] while the potential for onward displacement presents a risk of pharmacy defaulting and treatment interruptions. Displaced and conflict-affected populations may face challenges succeeding on HAART. We performed a systematic review of the literature on adherence to HAART and treatment outcomes in these groups, including refugees and internally-displaced persons (IDPs), assessed the quality of the evidence and suggest a future research program
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