Improving antiretroviraltherapy adherence inresource-limited settings at scale:a discussion ofinterventions and recommendations

Abstract

Introduction: Successful population-level antiretroviraltherapy (ART) adherence will be necessary to realize both the clinicaland prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV areadhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologicsuppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventionshave generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical,research, and public health experts for scalable ART adherence interventions in resource-limited settings.Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ARTadherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recentupdates. It is not a systematic review, but rather provides practical considerations for programme implementation based onevidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization ConsolidatedGuidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries.Interventions are categorized broadly as education and counselling; information and communication technology-enhancedsolutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category isdiscussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for thenear future. Approaches to intervention implementation and impact assessment are then described.Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventionsfor resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources.Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS).Many additional interventions could have an important impact on ART adherence with further development, including standardizedcounselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, andlivelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement.Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so thatthey do not limit the potential of ART to help bring about the end of AIDS.