Aging, antiretrovirals, and adherence: a meta analysis of adherence among older HIV-infected individuals

Abstract

Introduction: Older adults are generally considered to be at greater risk for medication non-adherence due to factors such as medication complexity, side effects, cost, and cognitive decline. However, this generalization may not apply to older adults with human immunodeficiency virus (HIV). Regardless of age, suboptimal adherence to antiretroviral therapy (ART) can lead to increased viral load, immunosuppression, drug-resistant viral strains, co-morbidities, and opportunistic infections. Understanding trends of adherence to ART among older adults is critical, especially as the population of people living with HIV grows older.

Objectives: The purpose of this systematic review and meta-analysis is to determine if older individuals with HIV are less likely to be non-adherent to antiretroviral therapy than younger individuals with HIV.

Design: A systematic search in PubMed, Embase, and PsycINFO was conducted to identify peer-reviewed articles evaluating adherence to ART in older adults. Two independent reviewers screened abstracts, applied inclusion criteria, and appraised study quality. The bibliographies of qualifying studies were searched. Data were abstracted from studies by two independent authors. Meta-analyses were conducted, and adherence levels were reported as the relative risk of non-adherence in older individuals compared to younger individuals.

Results: The systematic search yielded 1,848 abstracts. Twelve studies met full inclusion criteria. The overall meta-analysis found that older age reduced risk for nonadherence by 27 % (relative risk (RR) 0.72, 95 % confidence interval (CI) 0.64–0.82). Studies assessing both short-term and long-term adherence demonstrated a significant reduction in non-adherence among older patients (RR 0.75, 95 % CI 0.64–0.87 and RR 0.65, 95 % CI 0.50–0.85, respectively).

Conclusions: Older adults with HIV have a reduced risk for non-adherence to ART than their younger counterparts. Future studies should seek to elucidate contributing factors of adherence among older individuals with HIV.

Figure 1

PRIMSA Study Flow Diagram of the Systematic Review: The systematic literature review identified 1,848 abstracts, 101 of which were reviewed to identify the 12 included studies. PRISMA – Preferred Reporting for Items for Systematic Review and Meta Analysis; USPSTF – Unites States Preventative Services Task Force;

Figure 2

Forest Plots for the Overall Analysis and Sub-analyses of Measurement Time Frames. Panel A is a plot of the risk for non-adherence in older patients relative to younger patients across all studies. Panel B includes those studies that measured adherence for one month or less. Panel C includes those studies measuring adherence for longer than 1 month.

Figure 2

Forest Plots for the Overall Analysis and Sub-analyses of Measurement Time Frames. Panel A is a plot of the risk for non-adherence in older patients relative to younger patients across all studies. Panel B includes those studies that measured adherence for one month or less. Panel C includes those studies measuring adherence for longer than 1 month.

Figure 2

Forest Plots for the Overall Analysis and Sub-analyses of Measurement Time Frames. Panel A is a plot of the risk for non-adherence in older patients relative to younger patients across all studies. Panel B includes those studies that measured adherence for one month or less. Panel C includes those studies measuring adherence for longer than 1 month.

Figure 3

Forest Plots for the Sub-analyses of Measurement Type. Panel A are those studies that utilized a self report system. Panel B are those studies that used the Medication Event Monitoring System (MEMS Caps) which electronically record when a medication bottle is opened. Panel C is are those studies using pharmacy refill records to measure medication adherence.

Figure 3

Forest Plots for the Sub-analyses of Measurement Type. Panel A are those studies that utilized a self report system. Panel B are those studies that used the Medication Event Monitoring System (MEMS Caps) which electronically record when a medication bottle is opened. Panel C is are those studies using pharmacy refill records to measure medication adherence.