Abstract:
Background
Maintaining
high
levels
of adherence
to antiretroviral
therapy
(ART)
is a challenge
across
set-
tings
and
populations.
Understanding
the
relative
importance
of different
barriers
to adher-
ence
will
help
inform
the
targeting
of different
interventions
and
future
research
priorities.
Methods
and
Findings
We
searched
MEDLINE
via
PubMed,
Embase,
Web
of Science,
and
PsychINFO
from
01
January
1997
to 31
March
2016
for
studies
reporting
barriers
to adherence
to ART.
We
cal-
culated
pooled
proportions
of reported
barriers
to adherence
per
age
group
(adults,
adoles-
cents,
and
children).
We
included
data
from
125
studies
that
provided
information
about
adherence
barriers
for
17,061
adults,
1,099
children,
and
856
adolescents.
We
assessed
differences
according
to geographical
location
and
level
of economic
development.
The
most
frequently
reported
individual
barriers
included
forgetting
(adults
41.4%,
95%
CI
37.3%–45.4%;
adolescents
63.1%,
95%
CI
46.3%–80.0%;
children/caregivers
29.2%,
95%
CI
20.1%–38.4%)
, being
away
from
home
(adults
30.4%,
95%
CI
25.5%–35.2%
; adoles-
cents
40.7%,
95%
CI
25.7%–55.6%;
children/caregivers
18.5%,
95%
CI
10.3%–26.8%),
and
a change
to daily
routine
(adults
28.0%,
95%
CI
20.9%–35.0%;
adolescents
32.4%,
95%
CI
0%–75.0%;
children/caregiver
s 26.3%,
95%
CI
15.3%–37.4%
). Depression
wasreported
as
a barrier
to adherence
by
more
than
15%
of patients
across
all
age
categories
(adults
15.5%,
95%
CI
12.8%–18.3%;
adolescents
25.7%,
95%
CI
17.7%–33.6%;
children
15.1%,
95%
CI
3.9%–26.3%),
while
alcohol/substanc
e misuse
was
commonly
reported
by
adults
(12.9%,
95%
CI
9.7%–16.1%)
and
adolescents
(28.8%,
95%
CI
11.8%–45.8%).
Secrecy/stigma
was
a commonly
cited
barrier
to adherence,
reported
by
more
than
10%
of
adults
and
children
across
all
regions
(adults
13.6%,
95%
CI
11.9%–15.3%;
children/care-
givers
22.3%,
95%
CI
10.2%–34.5%).
Among
adults,
feeling
sick
(15.9%,
95%
CI
13.0%–
18.8%)
was
a more
commonly
cited
barrier
to adherence
than
feeling
well
(9.3%,
95%
CI
7.2%–11.4%).
Health
service–related
barriers,
including
distance
to clinic
(adults
17.5%,
95%
CI
13.0%–21.9%)
and
stock
outs
(adults
16.1%,
95%
CI
11.7%–20.4%),
were
also
fre-
quently
reported.
Limitations
of this
review
relate
to the
fact
that
included
studies
differed
in
approaches
to assessing
adherence
barriers
and
included
variable
durations
of follow
up.
Studies
that
report
self-reported
adherence
will
likely
underestimat
e the
frequency
of non-
adherence.
For
children,
barriers
were
mainly
reported
by
caregivers,
which
may
not
corre-
spond
to the
most
important
barriers
faced
by
children.
Conclusions
Patients
on
ART
face
multiple
barriers
to adherence,
and
no
single
intervention
will
be
suffi-
cient
to ensure
that
high
levels
of adherence
to treatment
and
virological
suppression
are
sustained.
For
maximum
efficacy,
health
providers
should
consider
a more
triaged
approach
that
first
identifies
patients
at risk
of poor
adherence
and
then
seeks
to establish
the
support
that
is needed
to overcome
the
most
important
barriers
to adherenc