Adherence to Antiretroviral Therapy in India: A Systematic Review and Meta-Analysis

Department of Internal Medicine, Division and Center for Evidence Based Medicine and Outcomes Research, Morsani College of Medicine, University of South Florida, Florida, USA
Indian Journal of Community Medicine 04/2013; 38(2):74-82. DOI: 10.4103/0970-0218.112435
Source: PubMed


To assess the adherence to antiretroviral therapy (ART) in the human immunodeficiency virus (HIV)-infected population in India.
Systematic review and meta-analysis.
The Medline and Cochrane library database were searched. Any prospective or retrospective study enrolling a minimum of 10 subjects with a primary objective of assessing ART adherence in the HIV population in India was included. Data were extracted on adherence definition, adherence estimates, study design, study population characteristics, recall period and assessment method. For metaanalysis, the pooled proportion was calculated as a back-transform of the weighted mean of the transformed proportions (calculated according to the Freeman-Tukey variant of the arcsine square root) using the random effects model.
There were seven cross-sectional studies and one retrospective study enrolling 1666 participants. Publication bias was significant (P = 0.003). Pooled results showed an ART adherence rate of 70% (95% confidence interval: 59-81%, I(2) = 96.3%). Sensitivity analyses based on study design, adherence assessment method and study region did not influence adherence estimates. Fifty percent (4/8) of the studies reported cost of medication as the most common obstacle for ART adherence. Twenty-five percent (2/8) reported lack of access to medication as the reason for non-adherence and 12% (1/8) cited adverse events as the most prevalent reason for non-adherence. The overall methodological quality of the included studies was poor.
Pooled results show that overall ART adherence in India is below the required levels to have an optimal treatment effect. The quality of studies is poor and cannot be used to guide policies to improve ART adherence.

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    • "Another meta-analysis in 2011, for Spanish patients on Highly Active Antiretroviral Therapy which dichotomized adherence at >90 and employed several methods for measuring adherence showed that 48.7% of the patients were adherent based on self-report with an overall percentage adherence of 55% (Ortego et al., 2011). A recent meta-analysis in 2013 for Indian patients on ART reported adherence of 77% (95% CI = 59% -81%), (Mhaskar et al., 2013). 50% of the studies use in the analysis by 'Mhaskar et al' reported cost of medication as the most common obstacle for ART adherence in India. "
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    ABSTRACT: As treatment of HIV infection with antiretroviral medications becomes a reality in sub-Saharan Africa, adherence to treatment regimen becomes a challenge. A meta-analysis was conducted to summarize the reported adherence rate in sub-Saharan Africa. Forest plot was used to visualize the extent of heterogeneity among studies. Following the random effect model, the combined adherence percent was 84.31% (95% CI = 79.48% -88.60%). The Monte Carlo sensitivity analysis provided an alternative statistical method to evaluate pooled proportion and the analysis was similar to the random effect analysis. Identified barriers to adherence include: depression, centralized ART clinic, interruption in drug supply/procurement, stigma, absence of social support, cost of ART, complacency, forgetfulness and medication related problems. Cost of ART (OR = 2.19; 95% CI= 1.65 – 2.90), Complacency (OR = 5.25; 95% CI = 2.89 – 10.80), and medication related problems (OR = 1.68; 95%CI = 1.28 – 2.22) were the strongest barriers to adherence. This study showed a good level of adherence in sub-Saharan Africa. However, barriers to adherence identified in this study could be employed to improve adherence to a near perfect level.
    Full-text · Article · Mar 2014
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    Full-text · Article · Jan 2010 · SAHARA J: journal of Social Aspects of HIV/AIDS Research Alliance / SAHARA , Human Sciences Research Council
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    ABSTRACT: Objective: India is home to the third-largest number of people living with HIV in the world, and no-cost antiretroviral therapy (ART) has been available across the country since 2004. However, rates of adherence to ART are often subpar in India, and interventions to increase adherence are warranted. Cognitive impairment and depression have been associated with ART non-adherence, and may also limit the impact of behavioral interventions designed to improve adherence. Studies have not evaluated the impact of cognitive impairment and depression on response to adherence interventions in India. Methods: Individuals new to ART (≤12 months prescribed) were recruited from a public hospital in Chandigarh, India. Participants (N = 80) were randomized to either a group medication adherence intervention (MAI) or an enhanced standard of care (ESOC) condition. The MAI consisted of three monthly gender-concordant group cognitive-behavioral sessions addressing HIV and ART, adherence, and HIV-related coping and social support. Participants were assessed at baseline for depression and cognitive functioning, and assessed monthly for adherence by pill count. Results: Adherence among participants receiving the MAI improved by about one day's dose over the course of the study, and no improvement was noted among those in the ESOC. Additionally, high rates of cognitive impairment (57%) and depression (25%) were identified among participants. There was no evidence that cognitive impairment moderated response to the intervention. However, while non-depressed participants benefitted from the intervention, depressed participants failed to show the same improvement. Conclusions: Results of this pilot study suggest that group behavioral interventions can be an effective strategy to promote ART adherence in this population, even among those demonstrating cognitive impairment. However, because of the negative impact of depression on adherence, future studies should continue to develop strategies to identify and treat it among people living with HIV in India.
    Full-text · Article · Apr 2014
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