Abstract
Introduction: Successful population‐level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale‐up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource‐limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource‐limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta‐analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low‐ and middle‐income countries. Interventions are categorized broadly as education and counselling; information and communication technology‐enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource‐limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi‐media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.
Highlights
Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, the end of AIDS
The vast majority of the 35 million people living with HIV (PLWH) are in resourcelimited settings (RLS), of whom an estimated 17 million were receiving ART in 2016 [4]
Because the global scale up of ART to meet World Health Organization (WHO) targets of near universal coverage [18] will stress existing healthcare delivery systems, effective interventions are presented in the context of scalability, which is defined as (1) acceptance by PLWH and providers, (2) consistency with the supply chain of necessary resources, and (3) affordability from the perspective of the healthcare system providing ART
Summary
Antiretroviral therapy (ART) has transformed HIV infection from a terminal disease into a manageable chronic illness [1]. Targets aim to increase the number on treatment to 20 million people by 2020 [4] While this ART expansion represents one of the greatest public health achievements of our time, much remains to be done. Shifts in ART initiation guidelines, including “test and start” and Option B+, in which all HIVpositive pregnant women start ART, highlight potential challenges for ART adherence and retention among ever-growing numbers of PLWH [5,6]. The level of adherence required to achieve improved immune function and viral suppression varies, depending primarily on ART regimen and prior duration of viral suppression [7]; consistent dosing without sustained gaps is critical for realizing both the individual and public health benefits of ART [8,9,10]. Because the global scale up of ART to meet WHO targets of near universal coverage [18] will stress existing healthcare delivery systems, effective interventions are presented in the context of scalability, which is defined as (1) acceptance by PLWH and providers, (2) consistency with the supply chain of necessary resources, and (3) affordability from the perspective of the healthcare system providing ART
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