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

Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
PLoS ONE (Impact Factor: 3.23). 05/2011; 6(5):e18948. DOI: 10.1371/journal.pone.0018948
Source: PubMed


We sought to examine the association between livelihood security and adherence to antiretroviral therapy (ARVs) in low- and middle-income countries (LIMC).
Performing 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.
Twenty 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).
Additional better quality research examining livelihood security is required to inform provision of optimal supports for adherence and mitigation of the impacts of HIV/AIDS.

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    • "Later on, among patients who have been on ART for longer periods, feeling better and experiencing an improvement in health can lead to an increased risk of stopping ART and missing scheduled visits [12], as patients believe that treatment is no longer necessary. Other factors, including treatment literacy (e.g., understanding the natural course of treatment and the need to take medication as prescribed), also matter for treatment adherence [29], [30]. "
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    ABSTRACT: Background Identifying follow-up (FU) visit patterns, and exploring which factors influence them are likely to be useful in determining which patients on antiretroviral therapy (ART) may become Lost to Follow-Up (LTFU). Using an operation and implementation research approach, we sought 1) to describe the timing of FU visits amongst patients who have been on ART for shorter and longer periods of time; and 2) to determine the median time to late visits, and 3) to identify specific factors that may be associated with these patterns in Zomba, Malawi. Methods and Findings Using routinely collected programme monitoring data from Zomba District, we performed descriptive analyses on all ART visits among patients who initiated ART between Jan. 1, 2007–June 30, 2010. Based on an expected FU date, each FU visit was classified as early (≥4 day before an expected FU date), on time (3 days before an expected FU date/up to 6 days after an expected FU date), or late (≥7 days after an expected FU date). In total, 7,815 patients with 76417 FU visits were included. Ninety-two percent of patients had ≥2 FU visits. At the majority of visits, patients were either on time or late. The median time to a first late visit among those with 2 or more visits was 216 days (IQR: 128–359). Various patient- and visit-level factors differed significantly across Early, On Time, and Late visit groups including ART adherence and frequency of, and type of side effects. Discussion The majority of patients do not demonstrate consistent FU visit patterns. Individuals were generally on ART for at least 6 months before experiencing their first late visit. Our findings have implications for the development of effective interventions that meet patient needs when they present early and can reduce patient losses to follow-up when they are late. In particular, time-varying visit characteristics need further research.
    Full-text · Article · Jul 2014 · PLoS ONE
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    • "Reported reasons for LTFU in Malawi and elsewhere have included: food insecurity [13-15], financial constraints [14,16,17], religious and family influences [14,16,18,19], wanting to access traditional medicine [20], stigma and fear of disclosure of HIV status [10,19-22], living far from clinics and transport-related costs [10,14,18,20,23], and poor patient-provider relationships [10,14,20]. Treatment literacy (e.g., understanding the natural course of treatment and the need for adherence to ART) [24,25], experiencing an improvement in health and believing that treatment is no longer necessary [10] may also matter. Some of these are consistent with the findings of our 2011 systematic review exploring livelihood factors and ART adherence [25] although we were limited by the available literature and could not identify new factors that may be relevant or specific to Malawi. "
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    ABSTRACT: Background Retention in antiretroviral therapy (ART) programmes remains a challenge in many settings including Malawi, in part due to high numbers of losses to follow-up. Concept Mapping (CM), a mix-method participatory approach, was used to explore why patients on ART are lost to follow-up (LTFU) by identifying: 1) factors that influence patient losses to follow-up and 2) barriers to effective and efficient tracing in Zomba, Malawi. Methods CM sessions (brainstorming, sorting and rating, interpretation) were conducted in urban and rural settings in Zomba, Malawi. Participants included ART patients, ART providers, Health Surveillance Assistants, and health managers from the Zomba District Health Office. In brainstorming, participants generated statements in response to “A specific reason why an individual on ART becomes lost to follow-up is…” Participants then sorted and rated the consolidated list of brainstormed items. Analysis included inductive qualitative methods for grouping of data and quantitative cluster identification to produce visual maps which were then interpreted by participants. Results In total, 90 individuals brainstormed 371 statements, 64 consolidated statements were sorted (participant n = 46), and rated on importance and feasibility (participant n = 69). A nine-cluster concept map was generated and included both patient- and healthcare-related clusters such as: Stigma and Fears, Beliefs, Acceptance and Knowledge of ART, Access to ART, Poor Documentation, Social and Financial Support Issues, Health Worker Attitudes, Resources Needed for Effective Tracing, and Health Worker Issues Related to Tracing. Strategies to respond to the clusters were generated in Interpretation. Conclusions Multiple patient- and healthcare focused factors influence why patients become LTFU. Findings have implications particularly for programs with limited resources struggling with the retention of ART patients.
    Full-text · Article · Jun 2013 · BMC Health Services Research
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    • "Common reasons reported for missed doses include financial trouble [38, 57] that prevent caregivers of children or adult patients from collecting medication on time [42], distance barrier or lack of transportation facilities to the ART clinic [37, 46], vomiting of medication without redosing, incorrect dosing by a caregiver, missed clinic appointments and pharmacy collections, confusion between multiple caregivers, and self-discontinuation or refusal by children [34, 58, 59]. Furthermore, patients' beliefs that medications need to be taken with food leads them to avoid taking medications whenever food is unavailable, interfering with adherence [42, 60]. "
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    ABSTRACT: Background. There are only a few comprehensive studies of adherence to ART and its challenges in Africa. This paper aims to assess the evidence on the challenges and prospects of ART adherence in sub-Saharan Africa. Methods. The authors reviewed original and review articles involving HIV-positive individuals that measured adherence to ART and its predictors in the past decade. Findings. Against expectations, sub-Saharan Africa patients have similar or higher adherence levels compared to those of developed countries. The challenges to ART adherence include factors related to patients and their families, socioeconomic factors, medication, and healthcare systems. Conclusion. Despite good adherence and program-related findings, antiretroviral treatment is challenged by a range of hierarchical and interrelated factors. There is substantial room for improvement of ART programs in sub-Sahara African countries.
    Full-text · Article · Feb 2012 · AIDS research and treatment
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