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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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.
KeywordsCommunity Interventions ART Adherence Retention LMIC
We thank Drs. Badara Samb and Martina Brostrom from the Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland, for their critical review and advises on this manuscript. Dr. Nachega receives research grant support from the National Institutes of Health/National Institutes for Allergy and Infectious Disease, the AIDS Clinical Trial Group (ACTG)/Stellenbosch University Clinical Trial Unit (2UM1AI069521-08); the US President Emergency Plan for AIDS Relief (PEPFAR; T84HA21652-01-00) for Medical Education Partnership Initiative; the Stellenbosch University Collaborative Capacity Enhancement through Engagement with Districts (SUCCEED; 1 U2GGH001536-01); and the Wellcome Trust Southern Africa Consortium for Research Excellence (WT087537MA). Dr. Altice is funded by the National Institutes on Drug Abuse for Research (R01-DA 10186; R01-DA 13805; R01-DA 017072). Dr. Uthman acknowledges support from the FAS Marie Curie International PostDoc (2012-0064).
Opinions expressed in the present manuscript are solely from authors and not from NIH, PEPFAR, WELLCOME TRUST, WHO, or UNAIDS.
JBN and EJM conceived the review. JBN, KP, and OA drafted the protocol. OA and JBN conducted eligibility of the searches and researched the data. JBN, OA, OAU, and AWK drafted the manuscript. The paper was revised critically for intellectual content by all the co-authors and gave final approval for publication.
Compliance with Ethical Standards
Conflict of Interest
Jean B. Nachega receives research grant support from the National Institutes of Health/National Institutes for Allergy and Infectious Disease, the AIDS Clinical Trial Group (ACTG)/Stellenbosch University Clinical Trial Unit (2UM1AI069521-08); the US President Emergency Plan for AIDS Relief (PEPFAR; T84HA21652-01-00) for Medical Education Partnership Initiative; the Stellenbosch University Collaborative Capacity Enhancement through Engagement with Districts (SUCCEED; 1 U2GGH001536-01); and the Wellcome Trust Southern Africa Consortium for Research Excellence (WT087537MA).
Olalekan A. Uthman acknowledges support from the FAS Marie Curie International PostDoc (2012-0064).
Frederick L. Altice is funded by the National Institutes on Drug Abuse for Research (R01-DA 10186; R01-DA 13805; R01-DA 017072).
Olatunji Adetokunboh, Amy W. Knowlton, Mauro Schechter, Omar Galárraga, 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
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
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