Adherence among women with HIV infection in Puerto Rico: the potential use of modified directly observed therapy (MDOT) among pregnant and postpartum women

Effects of Antihypertensive Therapy During Pregnancy on Postpartum Blood Pressure Control

OBJECTIVE

To compare differences in postpartum blood pressure (BP) control (BP below 140/90 mm Hg) for participants with hypertension randomized to receive antihypertensive treatment compared with no treatment during pregnancy.

METHODS

This study was a planned secondary analysis of a multicenter, open-label, randomized controlled trial (The CHAP [Chronic Hypertension and Pregnancy] trial). Pregnant participants with mild chronic hypertension (BP below 160/105 mm Hg) were randomized into two groups: active (antihypertensive treatment) or control (no treatment unless severe hypertension, BP 160/105 mm Hg or higher). Study outcomes were BP control below 140/90 mm Hg (primary) and medication nonadherence based on a composite score threshold (secondary) at the 6-week postpartum follow-up visit. Participants without follow-up BP measurements were excluded from analysis of the BP control outcome. Participants without health care professional-prescribed antihypertensives at delivery were excluded from the analysis of the adherence outcome. Multivariable logistic regression was used to adjust for potential confounders.

RESULTS

Of 2,408 participants, 1,684 (864 active, 820 control) were included in the analysis. A greater percentage of participants in the active group achieved BP control (56.7% vs 51.5%; adjusted odds ratio [aOR] 1.22, 95% CI, 1.00-1.48) than in the control group. Postpartum antihypertensive prescription was higher in the active group (81.7% vs 58.4%, P<.001), and nonadherence did not differ significantly between groups (aOR 0.81, 95% CI, 0.64-1.03).

CONCLUSION

Antihypertensive treatment of mild chronic hypertension during pregnancy was associated with better BP control below 140/90 mm Hg in the immediate postpartum period.

Experiences of people living with HIV in low- and middle-income countries and their perspectives in self-management: a meta-synthesis

INTRODUCTION

Availability of anti-retroviral treatment has changed HIV in to a manageable chronic disease, making effective self-management essential. However, only a few studies in low- and middle-income countries (LMICs) reported experiences of people living with HIV (PLWH) on self-management.

METHODS

This meta-synthesis of qualitative studies investigated perspectives of PLWH in LMICs on self-management. Various databases, including PubMed, EMBASE, EBSCO, and CINHAL, were searched through June 2022. Relevant additional articles were also included using cross-referencing of the identified papers. We used a thematic synthesis guided by the "Model of the Individual and Family Self-Management Theory" (IFSMT).

RESULT

PLWH in LIMICs experience a variety of challenges that restrict their options for effective self-management and compromises their quality of life. The main ones include: misconceptions about the disease, poor self-efficacy and self-management skills, negative social perceptions, and a non-patient-centered model of care that reduces the role of patients. The experiences that influenced the ability to practice self-management are summarized in context (the condition itself, physical and environmental factors, individual and family factors) and process factors (knowledge and beliefs, relationship with the health care worker, self-regulation skills and abilities, and social facilitation). Context and process greatly impacted quality of life through the self-management practices of the patients.

CONCLUSION AND RECOMMENDATION

PLWH encounter multiple challenges, are not empowered enough to manage their own chronic condition, and their needs beyond medical care are not addressed by service providers. Self-management practice of these patients is poor, and service providers do not follow service delivery approaches that empower patients to be at the center of their own care and to achieve an effective and sustainable outcome from treatment. These findings call for a comprehensive well thought self-management interventions.

Progress towards the UNAIDS 95-95-95 targets among pregnant women in South Africa: Results from the 2017 and 2019 national Antenatal HIV Sentinel Surveys

Objectives

The UNAIDS 95-95-95 global targets for epidemic control aim to ensure by 2030 that 95% of HIV-positive people know their HIV status, 95% of people diagnosed with HIV receive sustained antiretroviral therapy (ART), and 95% of people on ART have viral suppression. While data on the first and second 95 targets are routinely reported nationally, data on the third 95 target are not available for pregnant women in South Africa. The lack of data on the third 95 target limits the inclusion of low viral suppression as one of the contributing factors in MTCT root cause analyses. This study assessed progress towards the 95-95-95 targets among pregnant women between the ages of 15–49 years attending public health facilities in South Africa.

Method

Data were obtained from two consecutive national cross-sectional antenatal HIV sentinel surveys conducted between 1 October and 15 November in both 2017 and 2019. In each survey, data on age, knowledge of HIV status, ART initiation, and geographical location (province) were extracted from medical records. A blood specimen was collected from each woman and tested for HIV. Viral load tests were performed on HIV-positive specimens. Descriptive and multiple logistic regression analyses were performed to examine association between province and viral suppression (defined as viral load <50 copies/mL) using the combined dataset (i.e., both 2017 and 2019 data combined). All analyses considered the survey design.

Results

Of 10 065 and 11 321 HIV-positive women included in the 2017 and 2019 surveys, respectively, 96.0% (95% confidence interval (CI): 95.6–96.4%) and 97.6% (95% CI: 97.3–97.8%) knew their HIV-positive status; 86.6% (95% CI: 85.9–87.3%) and 96.0% (95% CI: 95.6–96.4%) of those who knew their HIV status were receiving ART; while 64.2% (95% CI: 63.2–65.2%) and 66.0% (95% CI: 65.1–66.8%) of those receiving ART were virally suppressed. Achievement of the third 95 target significantly varied by province ranging from 33.9–72.6% in 2017 and 43.4–77.3% in 2019. Knowledge of HIV-positive status, ART initiation, and viral suppression increased in both 15–24 and 25–49 year age groups between 2017 and 2019. In a multivariable analysis adjusting for survey year, gravidity, and education, the odds of viral suppression significantly varied by province (except KwaZulu-Natal and Western Cape, other provinces were less likely to attain viral suppression compared to Gauteng), age (adjusted odds ratio (AOR) for 15–24 years vs 25–49 years: 0.7, 95% CI: 0.6–0.8), and timing of ART initiation (AOR for ART initiation during pregnancy vs before pregnancy: 0.4, 95% CI: 0.5–0.6).

Conclusion

Although in 2019 the first and second 95 targets were achieved among pregnant women, meeting the third 95 target remains a challenge. This study highlighted the importance of promoting early ART initiation and the need to target young women in efforts to improve progress towards the third 95 target. Additionally, the provincial variation in viral suppression could be further investigated in future studies to identify and address the root causes underlying these differences.

Values and preferences of women living with HIV who are pregnant, postpartum or considering pregnancy on choice of antiretroviral therapy during pregnancy

OBJECTIVE

To investigate women's values and preferences regarding antiretroviral therapy (ART) during pregnancy to inform a BMJ Rapid Recommendation.

SETTING

Primary studies reporting patient-reported outcomes relevant to decision-making regarding ART in any clinical and geographical setting.

PARTICIPANTS

Women living with HIV who are pregnant, postpartum or considering pregnancy.

OUTCOME MEASURES

Quantitative measurements and qualitative descriptions of values and preferences in relation to ART during pregnancy. We also included studies on women's reported barriers and facilitators to adherence. We excluded studies correlating objective measures (eg, CD4 count) with adherence, or reporting only outcomes which are not expected to differ between ART alternatives (eg, access to services, knowledge about ART).

RESULTS

We included 15 qualitative studies reporting values and preferences about ART in the peripartum period; no study directly studied choice of ART therapy during pregnancy. Six themes emerged: a desire to reduce vertical transmission (nine studies), desire for child to be healthy (five studies), concern about side effects to the child (eight studies), desire for oneself to be healthy (five studies), distress about side effect to oneself (10 studies) and pill burden (two studies). None of the studies weighed the relative importance of these outcomes directly, but pill burden/medication complexity appears to be a lower priority for most women compared with other factors. Overall, the body of evidence was at low risk of bias, with minor limitations.

CONCLUSIONS

Women who are or may become pregnant and who are considering ART appear to place a high value on both their own and their children's health. Evidence on the relative importance between these values when choosing between ART regimens is uncertain. There is variability in individual values and preferences among women. This highlights the importance of an individualised women-centred approach, such as shared decision-making when choosing between ART alternatives.

TRIAL REGISTRATION NUMBER

International Prospective Register of Systematic Reviews:CRD42017057157.

Assessing health-related resiliency in HIV+ Latin women: Preliminary psychometric findings

BACKGROUND

HIV-associated vulnerabilities-especially those linked to psychological issues-and limited mental health-treatment resources have the potential to adversely affect the health statuses of individuals. The concept of resilience has been introduced in the literature to shift the emphasis from vulnerability to protective factors. Resilience, however, is an evolving construct and is measured in various ways, though rarely among underserved, minority populations. Herein, we present the preliminary psychometric properties of a sample of HIV-seropositive Puerto Rican women, measured using a newly developed health-related resilience scale.

METHODS AND DESIGN

The Resilience Scales for Children and Adolescents, an instrument with solid test construction properties, acted as a model in the development (in both English and Spanish) of the HRRS, providing the same dimensions and most of the same subscales. The present sample was nested within the Hispanic-Latino longitudinal cohort of women (HLLC), that is part of the NeuroAIDS Research Program at the University of Puerto Rico (UPR), Medical Sciences Campus (MSC). Forty-five consecutively recruited, HIV+ women from the HLLC completed a demographic survey, the HRRS, and the Beck Depression Inventory-I, Spanish version.

RESULTS

The results demonstrate excellent overall internal consistency for the total HRRS score (α = 0.95). Each of the dimensional scores also evidenced acceptable internal consistency (α ≥ 0.88). All the dimensional and subscale content validity indices were above the 0.42 cut-off. Analysis revealed a significant negative correlation between the HRRS total score and BDI-I-S (r(45) = -0.453, p < 0.003).

CONCLUSION

Albeit preliminary in nature, the present study provides support for the HRRS as a measure to assess resilience among individuals living with chronic medical conditions. Minority populations, especially non-English speaking ones, are understudied across the field of medicine, and when efforts are made to include these patient groups, measurement is rarely tailored to their unique cultural and linguistic experiences. The HRRS is a measure that addresses these notable voids in the medical literature.

Antiretroviral Adherence Perspectives of Pregnant and Postpartum Women in Guyana

The Caribbean region has the second highest HIV prevalence after Sub-Saharan Africa. Guyana's adult HIV prevalence is 1.9% among pregnant women, with women accounting for an estimated 58% of all persons living with HIV. However, there are few studies on ART adherence in the Caribbean, none from Guyana, and none focusing on adherence in pregnancy and the postpartum period. The objective of this study was to explore the perspectives of HIV-infected pregnant and postpartum women and healthcare providers in Guyana about barriers and facilitators to ART adherence. Data was collected using semi-structured interviews with 24 HIV-infected pregnant and postpartum women and nine healthcare professionals at five clinics between February and April 2012. The Framework Method for analysing qualitative data identified facilitators and barriers related to five core themes: (i) Concern for wellbeing of children; (ii) ART-related factors; (iii) Disclosure; (iv) Socio-economic issues; and (v) Religious and cultural beliefs. Non-disclosure did not adversely affect adherence, contrary to other studies in the literature. Two broad categories emerged from the lived experiences of women in Guyana. The first is related to the act of actually taking their medication where their tenacity is displayed in efforts made to ensure ART is taken. The second relates to the significance of ART to them in terms of reduced risk of MTCT, and the possibility of better health for themselves to enable them to care for their children. However, issues related to poverty, food insecurity and side effects reduced adherence need to be adequately addressed.

HIV/AIDS Competent Households: Interaction between a Health-Enabling Environment and Community-Based Treatment Adherence Support for People Living with HIV/AIDS in South Africa

In the context of severe human resource shortages in HIV care, task-shifting and especially community-based support are increasingly being cited as potential means of providing durable care to chronic HIV patients. Socio-ecological theory clearly stipulates that-in all social interventions-the interrelatedness and interdependency between individuals and their immediate social contexts should be taken into account. People living with HIV/AIDS (PLWHA) seldom live in isolation, yet community-based interventions for supporting chronic HIV patients have largely ignored the social contexts in which they are implemented. Research is thus required to investigate such community-based support within its context. The aim of this study is to address this research gap by examining the way in which HIV/AIDS competence in the household hampers or facilitates community-based treatment adherence support. The data was analyzed carefully in accordance with the Grounded Theory procedures, using Nvivo 10. More specifically, we analyzed field notes from participatory observations conducted during 48 community-based treatment adherence support sessions in townships on the outskirts of Cape Town, transcripts of 32 audio-recorded in-depth interviews with PLWHA and transcripts of 4 focus group discussions with 36 community health workers (CHWs). Despite the fact that the CHWs try to present themselves as not being openly associated with HIV/AIDS services, results show that the presence of a CHW is often seen as a marker of the disease. Depending on the HIV/AIDS competence in the household, this association can challenge the patient's hybrid identity management and his/her attempt to regulate the interference of the household in the disease management. The results deepen our understanding of how the degree of HIV/AIDS competence present in a PLWHA's household affects the manner in which the CHW can perform his or her job and the associated benefits for the patient and his/her household members. In this respect, a household with a high level of HIV/AIDS competence will be more receptive to treatment adherence support, as the patient is more likely to allow interaction between the CHW and the household. In contrast, in a household which exhibits limited characteristics of HIV/AIDS competence, interaction with the treatment adherence supporter may be difficult in the beginning. In such a situation, visits from the CHW threaten the hybrid identity management. If the CHW handles this situation cautiously and the patient-acting as a gate keeper-allows interaction, the CHW may be able to help the household develop towards HIV/AIDS competence. This would have a more added value compared to a household which was more HIV/AIDS competent from the outset. This study indicates that pre-existing dynamics in a patient's social environment, such as the HIV/AIDS competence of the household, should be taken into account when designing community-based treatment adherence programs in order to provide long-term quality care, treatment and support in the context of human resource shortages.

Effect of pregnancy and the postpartum period on adherence to antiretroviral therapy among HIV-infected women established on treatment

: Among women who become pregnant after initiating highly active antiretroviral therapy (HAART), few data describe the effect of pregnancy and postpartum on adherence. We conducted a retrospective clinical cohort study among therapy-naive women (age, 18-45 years) initiating HAART in Johannesburg, South Africa. Among 7510 women in our analysis, 896 experienced a pregnancy after starting HAART. Compared with nonpregnant periods of follow-up, there was an increased risk of nonadherence during the postpartum period (weighted risk ratio: 1.46, 95% confidence interval: 1.17 to 1.82) but not during pregnancy itself (weighted risk ratio: 0.95, 95% confidence interval: 0.78 to 1.17).

Policies and practices in the delivery of HIV services in correctional agencies and facilities: results from a multisite survey

HIV risk is disproportionately high among incarcerated individuals. Corrections agencies have been slow to implement evidence-based guidelines and interventions for HIV prevention, testing, and treatment. The emerging field of implementation science focuses on organizational interventions to facilitate adoption and implementation of evidence-based practices. A survey of correctional agency partners from the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) revealed that HIV policies and practices in prevention, detection, and medical care varied widely, with some corrections agencies and facilities closely matching national guidelines and/or implementing evidence-based interventions. Others, principally attributed to limited resources, had numerous gaps in delivery of best HIV service practices. A brief overview is provided of a new CJ-DATS cooperative research protocol, informed by the survey findings, to test an organization-level intervention to reduce HIV service delivery gaps in corrections.

Time to viral load suppression in antiretroviral-naive and -experienced HIV-infected pregnant women on highly active antiretroviral therapy: implications for pregnant women presenting late in gestation

OBJECTIVE

To compare time to achieve viral load <400 copies/ml and <1000 copies/ml in HIV-infected antiretroviral (ARV) -naive versus ARV-experienced pregnant women on highly active antiretroviral therapy (HAART).

DESIGN

Retrospective cohort study.

SETTING

Three university medical centers, USA.

POPULATION

HIV-infected pregnant women initiated or restarted on HAART during pregnancy.

METHODS

We calculated time to viral load <400 copies/ml and <1000 copies/ml in HIV-infected pregnant women on HAART who reported at least 50% adherence, stratifying based on previous ARV exposure history.

MAIN OUTCOME MEASURES

Time to HIV viral load <400 copies/ml and <1000 copies/ml.

RESULTS

We evaluated 138 HIV-infected pregnant women, comprising 76 ARV-naive and 62 ARV-experienced. Ninety-three percent of ARV-naive women achieved a viral load < 400 copies/ml during pregnancy compared with 92% of ARV-experienced women (P = 0.82). The median number of days to achieve a viral load < 400 copies/ml in the ARV-naive cohort was 25.0 (range 3.5-133; interquartile range 16-34) days compared with 27.0 (range 8-162.5; interquartile range 18.5-54.3) days in the ARV-experienced cohort (P = 0.02). In a multiple predictor analysis, women with higher adherence (adjusted relative hazard [aRH] per 10% increase in adherence 1.29, 95% confidence interval [CI] 1.08-1.54, P = 0.01) and receiving a non-nucleotide reverse transcriptase inhibitor (NNRTI) -based regimen (aRH 2.48, 95% CI 1.33-4.63, P = 0.01) were more likely to achieve viral load <400 copies/ml earlier. Increased baseline HIV log10 viral load was associated with a later time of achieving viral load <400 copies/ml (aRH 0.60, 95% CI 0.39-0.92, P = 0.02). In a corresponding model of time to achieve viral load <1000 copies/ml, adherence (aRH per 10% increase in adherence 1.79, 95% CI 1.34-2.39, P < 0.001), receipt of NNRTI (aRH 2.95, 95% CI 1.23-7.06, P = 0.02), and CD4 cell count (aRH per 50 count increase in CD4 1.12, 95% CI 1.03-1.22, P = 0.01) were associated with an earlier time to achieve viral load below this threshold. Increasing baseline HIV log10 viral load was associated with a longer time of achieving viral load <1000 copies/ml (aRH 0.54, 95% CI 0.34-0.86, P = 0.01). In multiple predictor models, previous ARV exposure was not significantly associated with time to achieve viral load below thresholds of <400 copies/ml and <1000 copies/ml.

CONCLUSIONS

Pregnant women with ≥50% adherence, whether ARV-naive or ARV-experienced, on average achieve a viral load <400 copies/ml within a median of 26 days and a viral load of <1000 copies/ml within a median of 14 days of HAART initiation. Increased adherence, receipt of NNRTI-based regimen and lower baseline HIV log10 viral load were all statistically significant predictors of earlier time to achieve viral load <400 copies/ml and <1000 copies/ml. Increased CD4 count was statistically significant as a predictor of earlier time to achieve viral load <1000 copies/ml.

Factors affecting antiretroviral therapy adherence among HIV-positive pregnant and postpartum women: an adapted systematic review

Summary

Adherence to antiretroviral therapy (ART) is crucial for effective treatment, but can be quite complex. Non-adherence can adversely affect treatment outcomes. Although many studies have been done on adherence in the general population, few have included HIV-positive pregnant and postpartum women in resource-constrained settings. This review assessed the evidence on adherence among these groups of women. A systematic search of databases was completed between June and July 2011. Both qualitative and quantitative studies were included. Eighteen studies from a total of 6622 satisfied the inclusion criteria that included inter alia facilitators and barriers to adherence. This review highlighted that there is still no consensus on the definition and measurement of adherence; also multiple factors can affect a woman's ability to adhere to ART. Some of the barriers and facilitators identified were similar in both the type of study (qualitative and quantitative) and among the various countries. Findings indicated that the few studies in this population are conducted primarily in resource-rich settings. Such paucity of information warrants urgent attention; thus targeted research is needed to provide insight on adherence within this population.

Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis

OBJECTIVE

To estimate antiretroviral therapy (ART) adherence rates during pregnancy and postpartum in high-income, middle-income, and low-income countries.

DESIGN

Systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, SCI Web of Science, NLM Gateway, and Google scholar databases were searched. We included all studies reporting adherence rates as a primary or secondary outcome among HIV-infected pregnant women. Two independent reviewers extracted data on adherence and study characteristics. A random-effects model was used to pool adherence rates; sensitivity, heterogeneity, and publication bias were assessed.

RESULTS

Of 72 eligible articles, 51 studies involving 20 153 HIV-infected pregnant women were included. Most studies were from United States (n =  14, 27%) followed by Kenya (n = 6, 12%), South Africa (n = 5, 10%), and Zambia (n = 5, 10%). The threshold defining good adherence to ART varied across studies (>80, >90, >95, 100%). A pooled analysis of all studies indicated a pooled estimate of 73.5% [95% confidence interval (CI) 69.3-77.5%] of pregnant women who had adequate (>80%) ART adherence. The pooled proportion of women with adequate adherence levels was higher during the antepartum (75.7%, 95% CI 71.5-79.7%) than during postpartum (53.0%, 95% CI 32.8-72.7%; P = 0.005). Selected reported barriers for nonadherence included physical, economic and emotional stresses, depression (especially postdelivery), alcohol or drug use, and ART dosing frequency or pill burden.

CONCLUSION

Our findings indicate that only 73.5% of pregnant women achieved optimal ART adherence. Reaching adequate ART adherence levels was a challenge in pregnancy, but especially during the postpartum period. Further research to investigate specific barriers and interventions to address them is urgently needed globally.

Adherence with drug therapy in pregnancy

Available information suggests that nonadherence with medication is a common problem in pregnant women. Not taking prescribed drugs may have potentially negative consequences as patients may not achieve their therapeutic goal. In addition to the many factors that may influence medication-taking behaviour in the general population, unique challenges are encountered in pregnant women as both maternal health and fetal well-being must be considered. On the one hand, pregnant women may be motivated to keep their underlying disease under control, while, on the other hand, fear and anxiety regarding the potential harmful effects of their medication on their unborn child may result in poor adherence with needed medication. Providing evidence-based information, ideally preconceptually, regarding the effects of their medication during pregnancy may be important in avoiding misperceptions that lead to nonadherence.

How does directly observed therapy work? The mechanisms and impact of a comprehensive directly observed therapy intervention of highly active antiretroviral therapy in Peru

From December 2005 through August 2008, we provided community-based accompaniment with supervised antiretroviral therapy (CASA) to impoverished individuals starting highly active antiretroviral therapy. Adherence support was provided for 18 months by a community-based team comprised of several nurses and two types of community health workers: field supervisors and directly observed therapy (DOT) volunteers. To complement our quantitative data collection in 2008 using purposive sampling, we conducted two gender-mixed focus group discussions with 13 CASA patient participants and 13 DOT volunteers from Lima, Peru to identify the mediating mechanisms by which CASA improved well-being, and to understand the benefits of the intervention, as perceived by these individuals. Using standard qualitative methods for the review and analysis of transcripts and interview notes, we identified central themes and developed a coding scheme for categorising participants' statements. Two individuals blinded to each other's coding, coded interview transcripts for theme and content from which a third reviewer compared their coding to arbitrate discrepancies. Additional domains were added if necessary and all domains were integrated into a theoretical scheme. Among the forms of support delivered by the CASA team, DOT volunteers reported emotional support, instrumental support, directly observed therapy, building trust, education, advocacy, exercise of moral authority and preparation for transition off CASA support. CASA participants described outcomes of improved adherence, ability to resume social roles, increased self-efficacy, hopefulness, changes in non-HIV-related behaviour, reduced internalised and externalised stigma, as well as ability to disclose. Both sets of focus group participants highlighted remaining challenges after completion of CASA support: stigma in the community, difficulties achieving economic recovery and persistent barriers to health services. Based on our prior quantitative and qualitative outcomes reported here, we argue that DOT of highly active antiretroviral therapy could be designed to optimise psychosocial recovery during the period of DOT.

Factors associated with condom use: economic security and positive prevention among people living with HIV/AIDS in the Caribbean

In the Caribbean region, an estimated 1.1% of the population aged 15-49 is living with HIV. We aimed to measure factors associated with condom use, the primary form of positive prevention in the Caribbean, among people living with HIV (PLHIV) in its major agency advocating on behalf of PLHIV (the Caribbean Regional Network of People Living with HIV/AIDS, or CRN +). Condom use at last sex was selected for analysis from a broad-ranging cross-sectional survey (n=394) among PLHIV who were members of or received services from CRN+ in Antigua and Barbuda, Grenada, Trinidad and Tobago. PLHIV from CRN+ traced potential participants, administered informed consent procedures and carried out structured interviews. Fifty-four percent of respondents reported using a condom the last time they had sex. Condom use was positively associated with partner being HIV negative, disclosure of HIV status, alcohol use, economic security, education level and being employed. Multivariate logistic regression found independent associations between condom use and economic security (p=0.031; odds ratio (OR) for "enough" income 5.06; 95% CI 1.47-17.39), partner being HIV negative (p=0.036; OR 2.85; 95% CI 1.28-6.33) and being married (p=0.043; OR 2.86; 95% CI 1.03-7.91). Seventy-three percent of respondents reported inadequate family income, 26% reported an HIV-negative partner and 9% were married. Condom use appears to be motivated by protection of HIV-negative partners and spouses. Low socioeconomic status is associated with the overall percentage using condoms. Restriction to members of CRN+ limits generalisability of the findings. Nevertheless, the findings support the view that programmes for the socioeconomic empowerment of PLHIV are needed to slow the Caribbean HIV epidemic. Expectations for protection of different types of partners should be further explored in order to develop culturally appropriate interventions with couples.

Effect of directly observed therapy for highly active antiretroviral therapy on virologic, immunologic, and adherence outcomes: a meta-analysis and systematic review

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/microL, 95% CI: 12 to 74 cells/microL), and HAART adherence of > or =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.

Strategies for promoting adherence to antiretroviral therapy: a review of the literature

The success of antiretroviral therapy (ART) for HIV infection, though widespread and resounding, has been limited by inadequate adherence to its unforgiving regimens, especially over the long term. This article summarizes the literature on behavioral interventions to promote ART adherence and highlights some of the most recent and innovative research on patient education and case management, modified directly observed therapy, contingency management, interventions emphasizing social support, and novel technologies to promote awareness. Research in the area of adherence in pediatric HIV infection and in resource-constrained international settings also is considered. Although adherence interventions have been successful in experimental trials, they may not be feasible or adaptable given the constraints of real-world clinics and community-based settings. Implementation and dissemination of adherence interventions needs increased attention as ART adherence research moves beyond its first decade. We conclude with suggestions for incorporating research findings into clinical practice.