Effect of Directly Observed Therapy for Highly Active Antiretroviral Therapy on Virologic, Immunologic, and Adherence Outcomes: A Meta-Analysis and Systematic Review

Abstract

Introduction Directly observed therapy of highly active antiretroviral therapy (DOT-HAART) is a feasible adherence intervention. Prospective DOT-HAART studies have shown mixed results, and optimal target groups have yet to be defined. We performed a meta-analysis and systematic review to assess the effect of DOT-HAART on adherence and virologic and immunologic response. Methods We performed a comprehensive search through August 2009 to identify peer-reviewed controlled studies that involved outpatient DOT-HAART among adults and reported at least 1 outcome assessed in this meta-analysis. Random-effects meta-analyses were performed; differences in effect on virologic suppression were examined using stratified meta-analyses and meta-regression on several study characteristics. Results Seventeen studies met inclusion criteria. Compared with control groups, DOT-HAART recipients were more likely to achieve an undetectable viral load (random effects risk ratio 1.24, 95% confidence interval (CI): 1.08 to 1.41), a greater increase in CD4 cell count (random effects weighted mean difference 43 cells/μL, 95% CI: 12 to 74 cells/μL), and HAART adherence of ≥95% (random effects risk ratio 1.17, 95% CI: 1.03 to 1.32). Results varied with respect to virologic response. DOT-HAART did not have a significant effect on virologic suppression when restricted to randomized controlled studies. Post-treatment effect was not observed in a limited number of studies. Conclusions DOT-HAART had a significant effect on virologic, immunologic, and adherence outcomes, although its efficacy was not supported when restricting analysis to randomized controlled trials. DOT-HAART shows greatest treatment effect when targeting individuals with greater risk of nonadherence and when delivering the intervention that maximizes participant convenience and provides enhanced adherence support. Further investigation is needed to assess the postintervention effect and cost-effectiveness of DOT-HAART.

Directly Observed Antiretroviral Therapy in Substance Abusers Receiving Methadone Maintenance Therapy Does Not Cause Increased Drug Resistance

“…25,26 In their analysis of DOT randomized clinical trials, Ford et al called into question the utility of DOT, finding no improvement in outcomes across broad U.S. and international study populations, except in certain high-risk populations. 25 In addition, Ford et al included measures after DOT had ended, which may have diluted the impact of DOT.…”

Comparison of clinical and laboratory profile of Haart adherent and non-adherent HIV/AIDS patients in Calabar, Nigeria

“…Akileswaran, et al, in a systematic review of HAART use in Africa reported improved clinical outcomes with optimal adherence in most studies reviewed (Akileswaran, 2005). This is in tune with the established role of HAART in significantly reducing viral load and increasing CD4 cell count, and thereby minimizing damage or insult to essential body cells and tissues, therefore retarding disease progression with improvement or restoration of immunity against opportunistic infections (Gross et al, 2006;Ferradini, 2006;Nieuwkerk and Oort, 2006;Gutierrez, 2006;Crum et al, 2006;Hart et al, 2010). The improved clinical outcome of adherent subjects in the present study may have been due to the fact that the cohorts were taking the medicines as revealed by the high rate of adherence and the effectiveness of the regimen.…”

Investing in Communities Achieves Results

“…Peer support improved the timeliness of clinical visits in South Africa, but the effect on actual adherence was weak. This result adds to the mixed picture of community-based adherence support provided by recent systematic reviews, with one systematic review finding no effect (Ford et al 2009) and another reporting positive effects (Hart et al 2010). Understating the factors that affect antiretroviral therapy (ART) adherence would be critical for defining a clear role for communities in this area and to improving and sustaining results.…”