Curr HIV/AIDS Rep (2014) 11:63–71 DOI 10.1007/s11904-013-0193-5
THE SCIENCE OF PREVENTION (SC KALICHMAN, SECTION EDITOR)
Antiretroviral Adherence Interventions in Southern Africa: Implications for Using HIV Treatments for Prevention Sarah Dewing & Cathy Mathews & Geoffrey Fatti & Ashraf Grimwood & Andrew Boulle
Published online: 5 January 2014 # Springer Science+Business Media New York 2014
Abstract There is concern that the expansion of ART (antiretroviral treatment) programmes to incorporate the use of treatment as prevention (TasP) may be associated with low levels of adherence and retention in care, resulting in the increased spread of drug-resistant HIV. We review research published over the past year that reports on interventions to improve adherence and retention in care in Southern Africa, and discuss these in terms of their potential to support the expansion of ART programmes for TasP. We found eight articles published since January 2012, seven of which were from South Africa. The papers describe innovative models for ART care and adherence support, some of which have the potential to facilitate the S. Dewing (*) : C. Mathews Health Systems Research Unit, Medical Research Council of South Africa, PO Box 19070, Tygerberg 7505, South Africa e-mail: [email protected] C. Mathews e-mail: [email protected] G. Fatti : A. Grimwood Kheth’Impilo, PO Box 13942, Mowbray 7705, Cape Town, South Africa G. Fatti e-mail: [email protected] A. Grimwood e-mail: [email protected] A. Boulle School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Falmouth Building, Observatory 7925, South Africa e-mail: [email protected] C. Mathews School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa C. Mathews Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
ongoing scale- up of treatment programmes for increased coverage and TasP. The extent to which interventions from South Africa can be effectively implemented in other, lower-resource Southern African countries is unclear. Keywords Antiretroviral adherence . Retention in care . Southern Africa . HIV/AIDS . HIV . Prevention . Science of prevention . South Africa . ART care . Treatment as prevention (TasP) . TASP
Introduction The provision of ART (antiretroviral treatment) for reducing the spread of HIV is rapidly gaining momentum. By suppressing an individual’s viral load, the greatest risk factor for HIV transmission, ART can substantially reduce their infectiousness [1]. ART is currently being used to successfully prevent the motherto-child-transmission of HIV in many countries worldwide [2–4]. There is also substantial evidence demonstrating that effective ART can prevent the transmission of HIV between sexual partners. Results from the landmark HIV Prevention Trials Network (HPTN) 052 trial showed that early ART initiation (i.e. before treatment was required for clinical benefit) led to a 96 % reduction in transmission in heterosexual HIVdiscordant couples [5]. Results from studies like HPTN 052 suggest the efficacy of this approach as a prevention strategy that could be used to reduce HIV transmission at population levels. Results from mathematical modelling studies suggest that this is possible [6], and one community-based study has shown that the effects observed in trials like HPTN052 can be replicated in real world settings [7]. HIV-uninfected individuals living in communities with high ART coverage1 (i.e. 30-40 %)
1 Coverage was defined in this study as the proportion of all HIV-infected individuals receiving ART [7].
64
were found to be 38 % less likely to acquire HIV than individuals in communities with ART coverage of less than 10 % [7]. Currently there are a considerable number of planned and ongoing research activities investigating ART for HIV prevention, including 12 large community trials [8]. The potential for ART to prevent HIV transmission has resulted in a push for early treatment initiation and the use of “treatment as prevention” (TasP) as a public health strategy to reduce the spread of HIV [9]. Given the burden of the cost of treating HIV in sub-Saharan Africa and the limited success of behavioural and other biomedical interventions in controlling generalised epidemics [1], TasP has significant economic, socio and biological appeal for curbing the epidemic. Some African countries are incorporating TasP strategies into national treatment guidelines [10]. Zambia and Nigeria recommend treatment initiation for sero-discordant couples irrespective of CD4 count [10]. Malawi recommends initiating ART for life in HIV-positive pregnant women, while Burundi recommends ART irrespective of CD4 count for the HIV-positive partners of HIV-negative pregnant women [10]. Adherence is the most important predictor of viral suppression [11, 12]. Treatment interruptions and poor dose adherence are associated with treatment failure and drug resistance [11, 13, 14]. The effectiveness of TasP in real life will depend, at least in part, on the willingness and ability of individuals on treatment to remain in care and adequately adhere to prescribed treatment regimens [15]. Low retention in care is currently a threat to clinical and programmatic outcomes in resource-limited settings in SSA [16]. Cornell et al. [17] have shown that retention in South Africa’s national ARV treatment programme (the largest in the world) has deteriorated over time and as more people have been enrolled in care. They found as few as 64 % of people initiating treatment between 2002 and 2007 were retained in care at 36 months. In more rural parts of Southern Africa, as many as 20 % of patients have been found not to return to clinics after initiating treatment, with only 52 % of patients remaining in care at 36 months [16]. Among patients who are retained in care, levels of antiretroviral adherence in SSA have generally been found to be high, with a majority of participants in adherence studies achieving >90 % adherence [18–23]. There is room for improvement, and accumulating evidence suggests that the rapid scale-up of ART in Africa is associated with a rising prevalence of drug resistance [24, 25]. There is concern that early treatment strategies like TasP will lead to further increases in acquired and transmitted drug resistance [25]. At this stage we cannot know if this will occur, and it is possible that the risk of increased drug-resistance will be outweighed by the reduction in new HIV infections associated with early treatment initiation [26]. Among other activities that are needed to strengthen health systems for TasP is the need for efforts to optimize adherence
Curr HIV/AIDS Rep (2014) 11:63–71
and retention in care in order for this strategy to be successful. Barnighausen et al. [15] recently reviewed the experimental evidence for interventions to improve the performance of HIV health systems for TasP in SSA, including studies published up to 2011. They found no experimental evidence for interventions aimed at improving patient retention in care, but they did find a number of well conducted randomised control trials (RCTs) on a range of interventions aimed at optimising treatment dose adherence. Their review shows that cognitive, behavioural, and mixed interventions which include emotional support can be effective at improving treatment dose adherence in this setting. However, intensive interventions that are directed towards the individual can be difficult to implement in practice in Southern Africa because of large numbers of patients and restricted financial and human resources [27•]. The current paper aims to build on the review of adherence support interventions by Barnighausen et al. by reviewing research published since January 2012 that reports on interventions to improve ART adherence and retention in care in Southern Africa. We describe the interventions that are being planned and tested, and discuss these in terms of their potential for supporting the expansion of ARV treatment programmes for TasP. We did not limit our review to experimental studies and included all articles reporting on process and outcome evaluations, regardless of design. Often the real-world utility of behaviour change interventions developed and tested in RCT settings is limited [28], and there is value in reviewing evaluations of interventions for ARV adherence having been transferred in to routine practice in Southern African settings, not necessarily in the context of RCTs. Recently a small number of non-experimental studies evaluating adherence support programmes being implemented as part of standard care practice have been published. This research could be a valuable source of guidance for the development of new evidence-based interventions that are responsive to the circumstances in which they are to be implemented [28].
Methods Studies were included if they reported evaluations of interventions or programmes aimed at supporting ART adherence and retention in care (process or outcome, quantitative or qualitative) from Zambia, Malawi, Mozambique, Zimbabwe, Namibia, Botswana and South Africa. Reviews of interventions for improving ARV adherence and retention in care in this region were eligible for inclusion as well. Pubmed, ScienceDirect and EBSCOhost were searched for Englishlanguage papers published since January 2012 using combinations of the search terms “antiretroviral therapy, highly active", "compliance, patient", “adherence, patient”, "Africa, Southern", "lost to follow-up", and "retention”.
Curr HIV/AIDS Rep (2014) 11:63–71
Results We found eight articles published since January 2012 that met our search criteria. Seven were from South Africa and one from Zambia. Five articles report on interventions for adherence and retention that are currently delivered as routine practice in South Africa and Zambia, although only three report adherence and/or retention outcomes. Three articles present evaluations of innovative interventions for improving adherence, one of which reported adherence outcomes. Table 1 presents a summary of the studies. Antiretroviral Adherence Interventions in Southern Africa One way in which capacity for health service delivery has been expanded in resource-limited countries is through the deployment of lay and community health workers [29], and it is this cadre of healthcare worker that is often tasked with ARV adherence support. In a RCT published subsequent to Barnighausen et al.’s [15] review, Peltzer et al. [27•] assessed the effectiveness of a lay health worker (LHW) led group intervention for improving adherence among patients attending an ARV clinic in KwaZulu-Natal, South Africa. Patients randomised to the intervention arm of the study received a series of three one-hour group sessions delivered once monthly in combination with standard of care, described as medical directive given by healthcare providers in the context of routine clinical visits. Intervention sessions focused on medication information, identifying and problem-solving barriers to adherence. Three months following delivery of the intervention, adherence-related knowledge had increased significantly among intervention participants but there was no impact on adherence-related motivation or behavioural skills, and no statistically significant impact on self-reported adherence. Rather, adherence improved in both arms over time. At baseline, 50 % and 47.9 % of intervention and control participants reported optimal adherence over the past four days. This improved to 98.3 % and 88.2 % at three-month followup. The authors argue that this reflects both a high standard of usual care and the ability of LHWs to provide support for adherence that is as effective as support provided by medical professionals. This does not explain why baseline levels of adherence were so low, and raises a question as to how reliable this self-reported adherence data is. Over the past year, two studies aimed at determining what is being delivered as standard care practice for adherence support in Cape Town, South Africa, have been published. Dewing et al. [30] conducted an evaluation of counselling delivered by clinic-based lay ARV adherence counsellors and found that counsellors relied mainly on information-giving and advice in order to address non-adherence. Myer et al. [31] investigated the education and counselling activities
65
delivered to patients in preparation for ART initiation. Patient preparation is widely considered a key determinant of treatment adherence, and is an important part of many ARV treatment programmes in SSA [31]. Directed at all people enrolling in treatment, patient preparation in Southern Africa generally takes the form of patient education and/or counselling delivered by counsellors or nurses prior to treatment initiation [31–34]. In their study, Myer et al. [31] found that patient education and counselling for treatment initiation was delivered in between three and seven sessions, in a one-on-one or group format, and sometimes a combination of both. Counsellors used different sets of education materials which varied in content and, because the availability of these materials was irregular, counselling was often delivered without any formal materials. There is little evidence to support the use of any of the approaches found by Dewing et al. [30] and Myer et al. [31] for promoting adherence and retention in care. In the context of concerns regarding the capacity of ARV treatment programmes to retain large numbers of people enrolling in care, the paucity of research around pre-treatment preparation for ART represents a gap in urgent need of attention [31]. One attempt to address this gap has been made by Remien et al. [35] who report on the development of a multimedia intervention that offers a standardised approach to preparing patients for treatment initiation and for optimising adherence. This computer-based intervention, called Masivukeni (“let’s wake up”), was designed to be used by non-professional (lay) counsellors to help patients to improve treatment adherence by enlisting the support of a treatment partner. Thus far the feasibility of delivering the intervention has been piloted in one Cape Town clinic [35], but no patientlevel outcome data has yet been published. The authors found the intervention to be acceptable to clinic staff and patients, and that it could be delivered within a busy clinic setting. One behavioural intervention that is of rapidly growing interest in resource-poor settings is the use of mobile phone messaging to facilitate social support and improve ARV adherence and retention in care. In a study published within the past year, Dean et al. [36] tested the feasibility of using SMS (short message service) communication to promote adherence among HIV-positive pregnant women attending antenatal care in Pretoria, South Africa (no outcome data was collected). In this small pilot study, seven women were provided with cell phones and airtime and connected to each other and a clinician via text messaging. Group members used SMS to ask and answer questions regarding medical information, and to send messages of encouragement to each other. This strategy was successful in connecting women with shared experience in a support group that overcame some of the barriers associated with conventional support forums, such as stigma and logistical challenge. Whether this intervention would result in improved adherence and retention in care is not yet known.
Country (city or region)
South Africa (Pretoria)
South Africa (Cape Town)
South Africa (Western Cape, KwaZulu-Natal, Eastern Cape and Mpumalanga)
South Africa (Cape Town)
South Africa (Cape Town)
South Africa (Kwa-Zulu Natal)
South Africa (Cape Town)
Authors
Dean et al. [36]
Dewing et al. [30]
Fatti et al. [41•]
Luque-Fernandez et al. [39•]
Myer et al. [31]
Peltzer et al. [27•]
Remien et al. [35]
After 39 months, 97 % of club patients remained in care vs. 85 % of non-club patients. Club participation reduced loss-to-care by 57 % (hazard ratio [HR] 0.43, 95 % CI=0.21–0.91) and virologic rebound by 67 % (HR 0.33, 95 % CI=0.16–0.67). Each NGO reported a different approach to patient preparation activities in terms of the number of sessions, education materials used and screening for mental-health and substance-related problems. At 3-month follow-up, adherence-related knowledge was significantly improved in intervention patients in comparison to standard of care patients (30.2 % vs. 28.4 %, p=048). There was no significant impact on adherence-related motivation (31.2 vs. 30.5, p=.379) or behavioural skills (45.6 vs. 46.4, p=.687). Adherence improved significantly in both conditions: the number of patients reported optimal adherence over the past 4 days improved from 50 % to 98.3 % in the intervention arm, and from 47.9 % to 88.2 % in the standard care arm (p=.341). Similarly for CD4 count which improved from a median of 308 to 384 in the intervention arm, and from 264 to 368 in the standard of care arm (p=.894).
2829 patients from one primary healthcare facility
11 Non-governmental organisations (NGOs) and 7 key informants
152 adult ART patients. Seventy-six received the intervention, while 76 received standard of care
Outcome evaluation: Retrospective cohort study
Process evaluation: Qualitative study
Outcome evaluation: Randomised controlled trial
Group intervention based on cognitive behavioural strategies and delivered by lay health workers.
Patient education and counselling delivered as part of routine care prior to ART initiation.
Adherence clubs.
33 patients, 2 counsellors, 6 clinic staff, 8 patients
After 5 years, patient retention in CBAS patients (n=19 668) was 79.1 % (95 % CI: 77.7 % to 80.4 %) vs. 73.6 % (95 % CI: 72.6 % to 74.5 %) in non-CBAS patients (n=47 285). After 6 months on ART, virological suppression was 76.6 % (95 % CI: 75.8 % to 77.5 %) in CBAS patients vs. 72 % (95 % CI: 71.3 % to 72.5 %) in non-CBAS patients (p
THE SCIENCE OF PREVENTION (SC KALICHMAN, SECTION EDITOR)
Antiretroviral Adherence Interventions in Southern Africa: Implications for Using HIV Treatments for Prevention Sarah Dewing & Cathy Mathews & Geoffrey Fatti & Ashraf Grimwood & Andrew Boulle
Published online: 5 January 2014 # Springer Science+Business Media New York 2014
Abstract There is concern that the expansion of ART (antiretroviral treatment) programmes to incorporate the use of treatment as prevention (TasP) may be associated with low levels of adherence and retention in care, resulting in the increased spread of drug-resistant HIV. We review research published over the past year that reports on interventions to improve adherence and retention in care in Southern Africa, and discuss these in terms of their potential to support the expansion of ART programmes for TasP. We found eight articles published since January 2012, seven of which were from South Africa. The papers describe innovative models for ART care and adherence support, some of which have the potential to facilitate the S. Dewing (*) : C. Mathews Health Systems Research Unit, Medical Research Council of South Africa, PO Box 19070, Tygerberg 7505, South Africa e-mail: [email protected] C. Mathews e-mail: [email protected] G. Fatti : A. Grimwood Kheth’Impilo, PO Box 13942, Mowbray 7705, Cape Town, South Africa G. Fatti e-mail: [email protected] A. Grimwood e-mail: [email protected] A. Boulle School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Falmouth Building, Observatory 7925, South Africa e-mail: [email protected] C. Mathews School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa C. Mathews Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
ongoing scale- up of treatment programmes for increased coverage and TasP. The extent to which interventions from South Africa can be effectively implemented in other, lower-resource Southern African countries is unclear. Keywords Antiretroviral adherence . Retention in care . Southern Africa . HIV/AIDS . HIV . Prevention . Science of prevention . South Africa . ART care . Treatment as prevention (TasP) . TASP
Introduction The provision of ART (antiretroviral treatment) for reducing the spread of HIV is rapidly gaining momentum. By suppressing an individual’s viral load, the greatest risk factor for HIV transmission, ART can substantially reduce their infectiousness [1]. ART is currently being used to successfully prevent the motherto-child-transmission of HIV in many countries worldwide [2–4]. There is also substantial evidence demonstrating that effective ART can prevent the transmission of HIV between sexual partners. Results from the landmark HIV Prevention Trials Network (HPTN) 052 trial showed that early ART initiation (i.e. before treatment was required for clinical benefit) led to a 96 % reduction in transmission in heterosexual HIVdiscordant couples [5]. Results from studies like HPTN 052 suggest the efficacy of this approach as a prevention strategy that could be used to reduce HIV transmission at population levels. Results from mathematical modelling studies suggest that this is possible [6], and one community-based study has shown that the effects observed in trials like HPTN052 can be replicated in real world settings [7]. HIV-uninfected individuals living in communities with high ART coverage1 (i.e. 30-40 %)
1 Coverage was defined in this study as the proportion of all HIV-infected individuals receiving ART [7].
64
were found to be 38 % less likely to acquire HIV than individuals in communities with ART coverage of less than 10 % [7]. Currently there are a considerable number of planned and ongoing research activities investigating ART for HIV prevention, including 12 large community trials [8]. The potential for ART to prevent HIV transmission has resulted in a push for early treatment initiation and the use of “treatment as prevention” (TasP) as a public health strategy to reduce the spread of HIV [9]. Given the burden of the cost of treating HIV in sub-Saharan Africa and the limited success of behavioural and other biomedical interventions in controlling generalised epidemics [1], TasP has significant economic, socio and biological appeal for curbing the epidemic. Some African countries are incorporating TasP strategies into national treatment guidelines [10]. Zambia and Nigeria recommend treatment initiation for sero-discordant couples irrespective of CD4 count [10]. Malawi recommends initiating ART for life in HIV-positive pregnant women, while Burundi recommends ART irrespective of CD4 count for the HIV-positive partners of HIV-negative pregnant women [10]. Adherence is the most important predictor of viral suppression [11, 12]. Treatment interruptions and poor dose adherence are associated with treatment failure and drug resistance [11, 13, 14]. The effectiveness of TasP in real life will depend, at least in part, on the willingness and ability of individuals on treatment to remain in care and adequately adhere to prescribed treatment regimens [15]. Low retention in care is currently a threat to clinical and programmatic outcomes in resource-limited settings in SSA [16]. Cornell et al. [17] have shown that retention in South Africa’s national ARV treatment programme (the largest in the world) has deteriorated over time and as more people have been enrolled in care. They found as few as 64 % of people initiating treatment between 2002 and 2007 were retained in care at 36 months. In more rural parts of Southern Africa, as many as 20 % of patients have been found not to return to clinics after initiating treatment, with only 52 % of patients remaining in care at 36 months [16]. Among patients who are retained in care, levels of antiretroviral adherence in SSA have generally been found to be high, with a majority of participants in adherence studies achieving >90 % adherence [18–23]. There is room for improvement, and accumulating evidence suggests that the rapid scale-up of ART in Africa is associated with a rising prevalence of drug resistance [24, 25]. There is concern that early treatment strategies like TasP will lead to further increases in acquired and transmitted drug resistance [25]. At this stage we cannot know if this will occur, and it is possible that the risk of increased drug-resistance will be outweighed by the reduction in new HIV infections associated with early treatment initiation [26]. Among other activities that are needed to strengthen health systems for TasP is the need for efforts to optimize adherence
Curr HIV/AIDS Rep (2014) 11:63–71
and retention in care in order for this strategy to be successful. Barnighausen et al. [15] recently reviewed the experimental evidence for interventions to improve the performance of HIV health systems for TasP in SSA, including studies published up to 2011. They found no experimental evidence for interventions aimed at improving patient retention in care, but they did find a number of well conducted randomised control trials (RCTs) on a range of interventions aimed at optimising treatment dose adherence. Their review shows that cognitive, behavioural, and mixed interventions which include emotional support can be effective at improving treatment dose adherence in this setting. However, intensive interventions that are directed towards the individual can be difficult to implement in practice in Southern Africa because of large numbers of patients and restricted financial and human resources [27•]. The current paper aims to build on the review of adherence support interventions by Barnighausen et al. by reviewing research published since January 2012 that reports on interventions to improve ART adherence and retention in care in Southern Africa. We describe the interventions that are being planned and tested, and discuss these in terms of their potential for supporting the expansion of ARV treatment programmes for TasP. We did not limit our review to experimental studies and included all articles reporting on process and outcome evaluations, regardless of design. Often the real-world utility of behaviour change interventions developed and tested in RCT settings is limited [28], and there is value in reviewing evaluations of interventions for ARV adherence having been transferred in to routine practice in Southern African settings, not necessarily in the context of RCTs. Recently a small number of non-experimental studies evaluating adherence support programmes being implemented as part of standard care practice have been published. This research could be a valuable source of guidance for the development of new evidence-based interventions that are responsive to the circumstances in which they are to be implemented [28].
Methods Studies were included if they reported evaluations of interventions or programmes aimed at supporting ART adherence and retention in care (process or outcome, quantitative or qualitative) from Zambia, Malawi, Mozambique, Zimbabwe, Namibia, Botswana and South Africa. Reviews of interventions for improving ARV adherence and retention in care in this region were eligible for inclusion as well. Pubmed, ScienceDirect and EBSCOhost were searched for Englishlanguage papers published since January 2012 using combinations of the search terms “antiretroviral therapy, highly active", "compliance, patient", “adherence, patient”, "Africa, Southern", "lost to follow-up", and "retention”.
Curr HIV/AIDS Rep (2014) 11:63–71
Results We found eight articles published since January 2012 that met our search criteria. Seven were from South Africa and one from Zambia. Five articles report on interventions for adherence and retention that are currently delivered as routine practice in South Africa and Zambia, although only three report adherence and/or retention outcomes. Three articles present evaluations of innovative interventions for improving adherence, one of which reported adherence outcomes. Table 1 presents a summary of the studies. Antiretroviral Adherence Interventions in Southern Africa One way in which capacity for health service delivery has been expanded in resource-limited countries is through the deployment of lay and community health workers [29], and it is this cadre of healthcare worker that is often tasked with ARV adherence support. In a RCT published subsequent to Barnighausen et al.’s [15] review, Peltzer et al. [27•] assessed the effectiveness of a lay health worker (LHW) led group intervention for improving adherence among patients attending an ARV clinic in KwaZulu-Natal, South Africa. Patients randomised to the intervention arm of the study received a series of three one-hour group sessions delivered once monthly in combination with standard of care, described as medical directive given by healthcare providers in the context of routine clinical visits. Intervention sessions focused on medication information, identifying and problem-solving barriers to adherence. Three months following delivery of the intervention, adherence-related knowledge had increased significantly among intervention participants but there was no impact on adherence-related motivation or behavioural skills, and no statistically significant impact on self-reported adherence. Rather, adherence improved in both arms over time. At baseline, 50 % and 47.9 % of intervention and control participants reported optimal adherence over the past four days. This improved to 98.3 % and 88.2 % at three-month followup. The authors argue that this reflects both a high standard of usual care and the ability of LHWs to provide support for adherence that is as effective as support provided by medical professionals. This does not explain why baseline levels of adherence were so low, and raises a question as to how reliable this self-reported adherence data is. Over the past year, two studies aimed at determining what is being delivered as standard care practice for adherence support in Cape Town, South Africa, have been published. Dewing et al. [30] conducted an evaluation of counselling delivered by clinic-based lay ARV adherence counsellors and found that counsellors relied mainly on information-giving and advice in order to address non-adherence. Myer et al. [31] investigated the education and counselling activities
65
delivered to patients in preparation for ART initiation. Patient preparation is widely considered a key determinant of treatment adherence, and is an important part of many ARV treatment programmes in SSA [31]. Directed at all people enrolling in treatment, patient preparation in Southern Africa generally takes the form of patient education and/or counselling delivered by counsellors or nurses prior to treatment initiation [31–34]. In their study, Myer et al. [31] found that patient education and counselling for treatment initiation was delivered in between three and seven sessions, in a one-on-one or group format, and sometimes a combination of both. Counsellors used different sets of education materials which varied in content and, because the availability of these materials was irregular, counselling was often delivered without any formal materials. There is little evidence to support the use of any of the approaches found by Dewing et al. [30] and Myer et al. [31] for promoting adherence and retention in care. In the context of concerns regarding the capacity of ARV treatment programmes to retain large numbers of people enrolling in care, the paucity of research around pre-treatment preparation for ART represents a gap in urgent need of attention [31]. One attempt to address this gap has been made by Remien et al. [35] who report on the development of a multimedia intervention that offers a standardised approach to preparing patients for treatment initiation and for optimising adherence. This computer-based intervention, called Masivukeni (“let’s wake up”), was designed to be used by non-professional (lay) counsellors to help patients to improve treatment adherence by enlisting the support of a treatment partner. Thus far the feasibility of delivering the intervention has been piloted in one Cape Town clinic [35], but no patientlevel outcome data has yet been published. The authors found the intervention to be acceptable to clinic staff and patients, and that it could be delivered within a busy clinic setting. One behavioural intervention that is of rapidly growing interest in resource-poor settings is the use of mobile phone messaging to facilitate social support and improve ARV adherence and retention in care. In a study published within the past year, Dean et al. [36] tested the feasibility of using SMS (short message service) communication to promote adherence among HIV-positive pregnant women attending antenatal care in Pretoria, South Africa (no outcome data was collected). In this small pilot study, seven women were provided with cell phones and airtime and connected to each other and a clinician via text messaging. Group members used SMS to ask and answer questions regarding medical information, and to send messages of encouragement to each other. This strategy was successful in connecting women with shared experience in a support group that overcame some of the barriers associated with conventional support forums, such as stigma and logistical challenge. Whether this intervention would result in improved adherence and retention in care is not yet known.
Country (city or region)
South Africa (Pretoria)
South Africa (Cape Town)
South Africa (Western Cape, KwaZulu-Natal, Eastern Cape and Mpumalanga)
South Africa (Cape Town)
South Africa (Cape Town)
South Africa (Kwa-Zulu Natal)
South Africa (Cape Town)
Authors
Dean et al. [36]
Dewing et al. [30]
Fatti et al. [41•]
Luque-Fernandez et al. [39•]
Myer et al. [31]
Peltzer et al. [27•]
Remien et al. [35]
After 39 months, 97 % of club patients remained in care vs. 85 % of non-club patients. Club participation reduced loss-to-care by 57 % (hazard ratio [HR] 0.43, 95 % CI=0.21–0.91) and virologic rebound by 67 % (HR 0.33, 95 % CI=0.16–0.67). Each NGO reported a different approach to patient preparation activities in terms of the number of sessions, education materials used and screening for mental-health and substance-related problems. At 3-month follow-up, adherence-related knowledge was significantly improved in intervention patients in comparison to standard of care patients (30.2 % vs. 28.4 %, p=048). There was no significant impact on adherence-related motivation (31.2 vs. 30.5, p=.379) or behavioural skills (45.6 vs. 46.4, p=.687). Adherence improved significantly in both conditions: the number of patients reported optimal adherence over the past 4 days improved from 50 % to 98.3 % in the intervention arm, and from 47.9 % to 88.2 % in the standard care arm (p=.341). Similarly for CD4 count which improved from a median of 308 to 384 in the intervention arm, and from 264 to 368 in the standard of care arm (p=.894).
2829 patients from one primary healthcare facility
11 Non-governmental organisations (NGOs) and 7 key informants
152 adult ART patients. Seventy-six received the intervention, while 76 received standard of care
Outcome evaluation: Retrospective cohort study
Process evaluation: Qualitative study
Outcome evaluation: Randomised controlled trial
Group intervention based on cognitive behavioural strategies and delivered by lay health workers.
Patient education and counselling delivered as part of routine care prior to ART initiation.
Adherence clubs.
33 patients, 2 counsellors, 6 clinic staff, 8 patients
After 5 years, patient retention in CBAS patients (n=19 668) was 79.1 % (95 % CI: 77.7 % to 80.4 %) vs. 73.6 % (95 % CI: 72.6 % to 74.5 %) in non-CBAS patients (n=47 285). After 6 months on ART, virological suppression was 76.6 % (95 % CI: 75.8 % to 77.5 %) in CBAS patients vs. 72 % (95 % CI: 71.3 % to 72.5 %) in non-CBAS patients (p
