Livelihood Security and Adherence to Antiretroviral Therapy in Low and Middle Income Settings: A Systematic Review

Abstract

IntroductionWe sought to examine the association between livelihood security and adherence to antiretroviral therapy (ARVs) in low- and middle-income countries (LIMC).MethodsPerforming a systematic review, we searched, independently and in duplicate, 7 electronic databases and 2 conference websites for quantitative surveys that examined the association between indicators of livelihood security and adherence to ARVs in LIMC between 2000–2010. Criteria for relevance were applied to complete papers (quantitative study with estimates of associations) and quality assessment was conducted on those deemed relevant. We performed three regressions to measure the association between each type of livelihood and adherence.ResultsTwenty original studies and 6 conference abstracts were included, the majority from Africa (n = 16). Seventeen studies and 3 conference abstracts were cross-sectional and 3 studies and 3 abstracts were prospective clinical cohort studies, with considerable variation in quality for studies of each design type. Among the diverse populations represented, we observed considerable variation in associations between measurements of livelihood indicators and increasingly accepted adherence measures, irrespective of study design or quality. A financial capital indicator, financial constraints/payment for ARV medication, was more commonly associated with non-adherence (3/5 studies). A human capital indicator, educational level, was most commonly associated with adherence (11/20 studies).DiscussionAdditional better quality research examining livelihood security is required to inform provision of optimal supports for adherence and mitigation of the impacts of HIV/AIDS.

Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS

“…In a large nationally representative sample of~5000 HIVinfected individuals in France, food privation was associated with increased odds of self-reported ART nonadherence among heterosexual men, and a trend toward increased odds of nonadherence among heterosexual women (168). Whereas few quantitative studies to date have documented associations between food insecurity and nonadherence in resource-poor settings (169), qualitative studies in Kenya, Uganda, Botswana, and Swaziland have observed that food insecurity is one of the most commonly cited barriers to ART treatment adherence (15,87,160,170). In addition to food insecurity, poverty and the attendant inability to afford user fees and transport fees are well known to adversely affect ART adherence in resource-limited settings (159,169).…”

“…Whereas few quantitative studies to date have documented associations between food insecurity and nonadherence in resource-poor settings (169), qualitative studies in Kenya, Uganda, Botswana, and Swaziland have observed that food insecurity is one of the most commonly cited barriers to ART treatment adherence (15,87,160,170). In addition to food insecurity, poverty and the attendant inability to afford user fees and transport fees are well known to adversely affect ART adherence in resource-limited settings (159,169). HAART treatment interruptions (171)(172)(173)(174) and average HAART adherence (175)(176)(177), in turn, are wellknown determinants of HIV treatment outcomes.…”

Gender-Specific Risk Factors for Virologic Failure in KwaZulu-Natal: Automobile Ownership and Financial Insecurity

“…Socioeconomic factors (e.g. level of a community’s economic development, degree of unemployment, economic and health resources), a subset of structural factors, in particular have great impact when there are competing demands in the face of constrained resources, such as low income, food insecurity or inadequate public transportation (18, 24–32). …”

Adherence in a pragmatic randomized controlled trial on prophylactic iron supplementation during pregnancy in Maputo, Mozambique

“…Extensive research has been undertaken to study the level of adherence and its impact on health outcomes in trials of various health interventions. In developing country settings, most studies on trial adherence have focused on antiretroviral therapy for HIV (4)(5)(6) . There are however limited data on the extent of adherence in trials of interventions other than HIV therapy in developing countries.…”