Review

. 2016 Oct;13(5):241-55.

doi: 10.1007/s11904-016-0325-9.

Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets

Jean B Nachega^{1

2

3}, Olatunji Adetokunboh⁴, Olalekan A Uthman^{4

5}, Amy W Knowlton⁶, Frederick L Altice⁷, Mauro Schechter⁸, Omar Galárraga⁹, Elvin Geng¹⁰, Karl Peltzer^{11

12

13}, Larry W Chang⁶, Gilles Van Cutsem¹⁴, Shabbar S Jaffar¹⁵, Nathan Ford¹⁶, Claude A Mellins¹⁷, Robert H Remien¹⁸, Edward J Mills¹⁹

Affiliations

¹ University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA. jbn16@pitt.edu.
² Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa. jbn16@pitt.edu.
³ Johns Hopkins University, Baltimore, MD, USA. jbn16@pitt.edu.
⁴ Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa.
⁵ Warwick Medical School, The University of Warwick, Coventry, UK.
⁶ Johns Hopkins University, Baltimore, MD, USA.
⁷ Yale University School of Medicine and Public Health, Yale, CT, USA.
⁸ Projeto Praça Onze, Rio de Janeiro, Brazil.
⁹ Brown University School of Public Health, Providence, RI, USA.
¹⁰ University of California, San Francisco, CA, USA.
¹¹ Mahidol University, Salaya, Thailand.
¹² University of Limpopo, Polokwane, South Africa.
¹³ Human Sciences Research Council, Pretoria, South Africa.
¹⁴ Médecins Sans Frontières, Cape Town, South Africa.
¹⁵ Liverpool School of Tropical Medicine, Liverpool, UK.
¹⁶ World Health Organization, Geneva, Switzerland.
¹⁷ HIV Center for Clinical and Behavioral Studies, Columbia University, New York, NY, USA.
¹⁸ New York State Psychiatric Institute, New York, NY, USA.
¹⁹ Precision Global Health, Vancouver, Canada.

PMID: 27475643
PMCID: PMC5357578
DOI: 10.1007/s11904-016-0325-9

Review

Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets

Jean B Nachega et al. Curr HIV/AIDS Rep. 2016 Oct.

. 2016 Oct;13(5):241-55.

doi: 10.1007/s11904-016-0325-9.

Authors

Affiliations

¹ University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA. jbn16@pitt.edu.
² Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa. jbn16@pitt.edu.
³ Johns Hopkins University, Baltimore, MD, USA. jbn16@pitt.edu.
⁴ Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa.
⁵ Warwick Medical School, The University of Warwick, Coventry, UK.
⁶ Johns Hopkins University, Baltimore, MD, USA.
⁷ Yale University School of Medicine and Public Health, Yale, CT, USA.
⁸ Projeto Praça Onze, Rio de Janeiro, Brazil.
⁹ Brown University School of Public Health, Providence, RI, USA.
¹⁰ University of California, San Francisco, CA, USA.
¹¹ Mahidol University, Salaya, Thailand.
¹² University of Limpopo, Polokwane, South Africa.
¹³ Human Sciences Research Council, Pretoria, South Africa.
¹⁴ Médecins Sans Frontières, Cape Town, South Africa.
¹⁵ Liverpool School of Tropical Medicine, Liverpool, UK.
¹⁶ World Health Organization, Geneva, Switzerland.
¹⁷ HIV Center for Clinical and Behavioral Studies, Columbia University, New York, NY, USA.
¹⁸ New York State Psychiatric Institute, New York, NY, USA.
¹⁹ Precision Global Health, Vancouver, Canada.

PMID: 27475643
PMCID: PMC5357578
DOI: 10.1007/s11904-016-0325-9

Abstract

Little is known about the effect of community versus health facility-based interventions to improve and sustain antiretroviral therapy (ART) adherence, virologic suppression, and retention in care among HIV-infected individuals in low- and middle-income countries (LMICs). We systematically searched four electronic databases for all available randomized controlled trials (RCTs) and comparative cohort studies in LMICs comparing community versus health facility-based interventions. Relative risks (RRs) for pre-defined adherence, treatment engagement (linkage and retention in care), and relevant clinical outcomes were pooled using random effect models. Eleven cohort studies and eleven RCTs (N = 97,657) were included. Meta-analysis of the included RCTs comparing community- versus health facility-based interventions found comparable outcomes in terms of ART adherence (RR = 1.02, 95 % CI 0.99 to 1.04), virologic suppression (RR = 1.00, 95 % CI 0.98 to 1.03), and all-cause mortality (RR = 0.93, 95 % CI 0.73 to 1.18). The result of pooled analysis from the RCTs (RR = 1.03, 95 % CI 1.01 to 1.06) and cohort studies (RR = 1.09, 95 % CI 1.03 to 1.15) found that participants assigned to community-based interventions had statistically significantly higher rates of treatment engagement. Two studies found community-based ART delivery model either cost-saving or cost-effective. Community- versus facility-based models of ART delivery resulted in at least comparable outcomes for clinically stable HIV-infected patients on treatment in LMICs and are likely to be cost-effective.

Keywords: ART; Adherence; Community; Interventions; LMIC; Retention.

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Conflict of interest statement

Compliance with Ethical Standards

Conflict of Interest

Olatunji Adetokunboh, Amy W. Knowlton, Mauro Schechter, Omar Gálarraga, Elvin Geng, Karl Peltzer, Larry W. Chang, Gilles Van Cutsem, Shabbar S. Jaffar, Nathan Ford, Claude A. Mellins, Robert H. Remien, and Edward J. Mills declare that they have no conflict of interest

Figures

**Fig. 1**
PRISMA flow for study selection

**Fig. 2**
Forest plot of optimal ART adherence comparing community-based ART versus facility-based ART

**Fig. 3**
Forest plot of virologic suppression comparing community-based ART versus facility-based ART

**Fig. 4**
Forest plot of retention in care comparing community-based ART versus facility-based ART

**Fig. 5**
Forest plot of all-cause mortality comparing community-based ART versus facility-based ART

See this image and copyright information in PMC

References

1. Joint United Nations Programme on HIV/AIDS (UNAIDS) Report on the global AIDS epidemic 2015. Geneva, Switzerland: UNAIDS; 2015.
1. Ford N, Mills EJ. Simplified ART delivery models are needed for the next phase of scale up. PLoS Med. 2011;8:el001060. - PMC - PubMed
1. Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90: an ambitious treatment target to help end the aids epidemic. Geneva, Switzerland: UNAIDS; 2014.
1. World Health Organization. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Geneva, Switzerland: WHO; [Accessed March 3, 2016]. p. 2015. [URL: http://apps.who.int/iris/bitstream/l0665/186275/l/9789241509565_eng.pdf. Latest WHO Consolidated ART Guidelines
1. Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52:793–800. - PMC - PubMed

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Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets

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Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets

Authors

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