Adherence-enhancing interventions for active antiretroviral therapy in sub-Saharan Africa: a systematic review and meta-analysis

Background: In sub-Saharan Africa, an estimated 23% of HIV-infected patients are nonadherent. The objective was to evaluate the effectiveness of adherence-enhancing interventions for active antiretroviral therapy (ART) in HIV-infected patients in sub-Saharan Africa. Methods: A systematic literature search was performed with the following inclusion criteria: adult HIV patients treated with ART, an intervention to enhance patient adherence, adherence rate as an outcome, a clinical or patient outcome, a randomised controlled trial and conducted in sub-Saharan Africa. Studies were selected by two reviewers independently. Data on patient characteristics, interventions, adherence definition and measures, and results were extracted. The risk of bias was evaluated by two reviewers independently. A meta-analysis was performed where appropriate. All discrepancies were discussed until consensus. Results: Six trials fulfilled all inclusion criteria. One showed statistically significant results in favour of the intervention for adherence rate and clinical outcome. The other studies showed either no significant results for any outcome or heterogeneous results depending on the outcome type. Aside from the clinical outcomes in one study, all outcomes showed a tendency in favour of the intervention groups. In the meta-analysis short message service (SMS) interventions showed a statistically significant effect on adherence (risk difference = -0.10; 95% confidence interval (CI): -0.17 to -0.03) and modified directly observed therapy (DOT) showed a significant effect on mortality (relative risk = 0.75; 95% CI: 0.44-1.26). Conclusion: The adherence-enhancing interventions (DOT, SMS interventions, counselling plus an alarm device) increased adherence only slightly, possibly because the high baseline adherence causes a ceiling effect.