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

aDepartment of International Health bDepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA cDepartment of Medicine dCentre for Infectious Diseases eCenter for Evidence-based Healthcare, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa fDepartment of Primary Care Sciences, Keele University, Staffordshire, UK gDepartment of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland, USA hHuman Sciences Research Council, Pretoria iUniversity of the Free State, Bloemfontein jDepartment of Pediatrics and Child Health, Tygerberg's Children Hospital, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa kFaculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada lTrend Research Centre, Asia University, Taichung, Taiwan mCentre for Infectious Disease Research, Lusaka, Zambia nUniversity of Alabama at Birmingham, Birmingham, Alabama, USA oAnova Health Institute, Johannesburg pSchool of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa qPediatric, Adolescent and Maternal AIDS Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA.
AIDS (London, England) (Impact Factor: 6.56). 08/2012; 26(16):2039-2052. DOI: 10.1097/QAD.0b013e328359590f
Source: PubMed

ABSTRACT 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.

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