Randomized control trial of peer-delivered, modified directly observed therapy for HAART in Mozambique.
ABSTRACT To assess the efficacy of a peer-delivered intervention to promote short-term (6-month) and long-term (12-month) adherence to HAART in a Mozambican clinic population.
A 2-arm randomized controlled trial was conducted between October 2004 and June 2006.
Of 350 men and women (> or = 18 years) initiating HAART, 53.7% were female, and 97% were on 1 fixed-dose combination pill twice a day.
Participants were randomly assigned to receive 6 weeks (Monday through Friday; 30 daily visits) of peer-delivered, modified directly observed therapy (mDOT) or standard care. Peers provided education about treatment and adherence and sought to identify and mitigate adherence barriers.
Participants' self-reported medication adherence was assessed 6 months and 12 months after starting HAART. Adherence was defined as the proportion of prescribed doses taken over the previous 7 days. Statistical analyses were performed using intention-to-treat (missing = failure).
Intervention participants, compared to those in standard care, showed significantly higher mean medication adherence at 6 months (92.7% vs. 84.9%, difference 7.8, 95% confidence interval [CI]: 0.0.02, 13.0) and 12 months (94.4% vs. 87.7%, difference 6.8, 95% CI: 0.9, 12.9). There were no between-arm differences in chart-abstracted CD4 counts.
A peer-delivered mDOT program may be an effective strategy to promote long-term adherence among persons initiating HAART in resource-poor settings.
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ABSTRACT: Objectives In response to the lack of evidence-based guidance for how to continue scaling up antiretroviral therapy (ART) in ways that make optimal use of limited resources, to assess comparative studies of ART service delivery models implemented in sub-Saharan Africa.MethodsA systematic literature search and analysis of studies that compared two or more methods of ART service delivery using either CD4 count or viral load as a primary outcome.ResultsMost studies identified in this review were small and non-randomised, with low statistical power. Four of the 30 articles identified by this review conclude that nurse management of ART compares favourably to physician management. Seven provide evidence of the viability of managing ART at lower levels within the health system, and one indicates that vertical and integrated ART programmes can achieve similar outcomes. Five articles show that community/home-based ART management can be as effective as facility-based ART management. Five of seven articles investigating community support link it to better clinical outcomes. The results of four studies suggest that directly observed therapy may not be an important component of ART programmes.Conclusions Given that the scale-up of antiretroviral therapy represents the most sweeping change in healthcare delivery in sub-Saharan Africa in recent years, it is surprising to not find more evidence from comparative studies to inform implementation strategies. The studies reported on a wide range of service delivery models, making it difficult to draw conclusions about some models. The strongest evidence was related to the feasibility of decentralisation and task-shifting, both of which appear to be effective strategies.Tropical Medicine & International Health 07/2014; 19(10). DOI:10.1111/tmi.12366 · 2.30 Impact Factor
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ABSTRACT: Purpose This study systematically reviewed research on behavioral interventions based on the information-motivation-behavioral skills (IMB) model to investigate specific intervention strategies that focus on information, motivation, and behavioral skills and to evaluate their effectiveness for people with chronic diseases. Methods A systematic review was conducted in accordance with the guidelines of both the National Evidence-based Healthcare Collaborating Agency and Im and Chang. A literature search was conducted using electronic databases. Randomized controlled trials that tested behavioral interventions based on the IMB model for promoting health behaviors among people with chronic diseases were included. Four investigators independently reviewed the studies and assessed the quality of each study. A narrative synthesis was used. Results A total of 12 studies were included in the review. Nine studies investigated patients with HIV/AIDS. The most frequently used intervention strategies were instructional pamphlets for the information construct, motivational interviewing techniques for the motivation construct, and instruction or role playing for the behavioral skills construct. Ten studies reported significant behavior changes at the first post-intervention assessment. Conclusion This review indicates the potential strength of the IMB model as a theoretical framework to develop behavioral interventions. The specific integration strategies delineated for each construct of the model can be utilized to design model-based interventions.Asian Nursing Research 08/2014; 8(3). DOI:10.1016/j.anr.2014.08.002 · 0.42 Impact Factor
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ABSTRACT: We sought to review the effectiveness of interventions designed to improve adherence to antiretroviral therapy (ART) from studies included in a recent Cochrane review that reported a clinical and an adherence outcome, with at least 80% follow-up for 6 months or more. Data were extracted independently and in duplicate, with an adjudicator for disagreements. Risk of bias was assessed using the Cochrane Risk of Bias tool. Of 182 relevant studies in the Cochrane review, 49 were related to ART. Statistical pooling was not warranted due to heterogeneity in interventions, participants, treatments, adherence measures and outcomes. Many studies had high risk of bias in elements of design and outcome ascertainment. Only 10 studies improved both adherence and clinical outcomes. These used the following interventions: adherence counselling (two studies); a once-daily regimen (compared to twice daily); text messaging; web-based cognitive behavioral intervention; face-to-face multi-session intensive behavioral interventions (two studies); contingency management; modified directly observed therapy; and nurse-delivered home visits combined with telephone calls. Patient-related adherence interventions were the most frequently tested. Uniform adherence measures and higher quality studies of younger populations are encouraged.AIDS patient care and STDs 03/2015; 29(5). DOI:10.1089/apc.2014.0308 · 3.58 Impact Factor