Determinants of adherence to antiretroviral therapy among HIV-positive adults in sub-Saharan Africa: a systematic review

Abstract

ObjectiveThe rapid scale up of antiretroviral treatment (ART) in sub-Saharan Africa (SSA) has resulted in an increased focus on patient adherence. Non-adherence can lead to drug-resistant HIV caused by failure to achieve maximal viral suppression. Optimal treatment requires the identification of patients at high risk of suboptimal adherence and targeted interventions. The aim of this review was to identify and summarise determinants of adherence to ART among HIV-positive adults.DesignSystematic review of adherence to ART in SSA from January 2002 to October 2014.MethodsA systematic search was performed in 6 databases (PubMed, Cochrane Library, EMBASE, Web of Science, Popline, Global Health Library) for qualitative and quantitative articles. Risk of bias was assessed. A meta-analysis was conducted for pooled estimates of effect size on adherence determinants.ResultsOf the 4052 articles screened, 146 were included for final analysis, reporting on determinants of 161 922 HIV patients with an average adherence score of 72.9%. Main determinants of non-adherence were use of alcohol, male gender, use of traditional/herbal medicine, dissatisfaction with healthcare facility and healthcare workers, depression, discrimination and stigmatisation, and poor social support. Promoters of adherence included counselling and education interventions, memory aids, and active disclosure among people living with HIV. Determinants of health status had conflicting influence on adherence.ConclusionsThe sociodemographic, psychosocial, health status, treatment-related and intervention-related determinants are interlinked and contribute to optimal adherence. Clinics providing ART in SSA should therefore design targeted interventions addressing these determinants to optimise health outcomes.

Perceptions and decision-making with regard to pregnancy among HIV positive women in rural Maputo Province, Mozambique – a qualitative study

“…This study echoes many of the findings in the above countries which revealed how low adherence to antiretroviral therapy was related to several other significant factors: fear of HIV disclosure [50, 51]; stigma and discrimination; side effects of antiretroviral drugs [49, 52]; transportation costs; and long waiting periods at health facilities to obtain antiretroviral drugs [48, 53, 54]. A further factor was the inadequate use of modern contraceptives.…”

A proposed management algorithm for late-onset efavirenz neurotoxicity

“…There are almost twice as many women (compared with men) on ART in SA, [15] and women have higher rates of adherence to ART. [15,16] Our patients all had considerable (asymptomatic) exposure to ART prior to presentation (although this varied widely from 5 months to 4 years), qualifying our defini tion of 'late-onset' EFV toxicity. Our patients had all recently been commenced on INH (either in the form of prophylaxis or as part of TB treatment) with an average of 3 months' INH use prior to symptom onset.…”

‘I told her this is your life’: relationship dynamics, partner support and adherence to antiretroviral therapy among South African couples

“…High levels of adherence to ART are needed to prevent virologic failure, the development and spread of drug-resistant strains of HIV, and to achieve viral suppression (Simoni et al 2006), which is necessary to prevent the spread of HIV to uninfected partners (Rodger et al 2014). However, in sub-Saharan Africa, adherence is suboptimal with estimates of 72.9% (Heestermans et al 2016). Greater attention to adherence is critical given the shift towards a ‘test and treat’ approach (WHO 2015)—which will dramatically increase the number of individuals on ART.…”

“…This is supported by qualitative studies showing that fears around IPV limit partner disclosure, and that disclosure can trigger new incidents of violence (Colombini, James, and Ndwiga 2016, Mulrenan et al 2015). At the individual level, psychosocial and behavioral factors such as negative beliefs about HIV treatment, alcohol use, and depression have been associated with suboptimal adherence (Kagee et al 2011, Nozaki et al 2013, Nakimuli-Mpungu et al 2012, Dahab et al 2008, Heestermans et al 2016). …”