Current HIV/AIDS Reports

, Volume 13, Issue 5, pp 241–255 | Cite as

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. NachegaEmail author
  • Olatunji Adetokunboh
  • Olalekan A. Uthman
  • Amy W. Knowlton
  • Frederick L. Altice
  • 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
  • Edward J. Mills
The Global Epidemic (SH Vermund, Section Editor)
Part of the following topical collections:
  1. Topical Collection on The Global Epidemic


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.


Community 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.

Authors’ Contributions

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.

Supplementary material

11904_2016_325_MOESM1_ESM.docx (14 kb)
ESM 1 (DOCX 14 kb)


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Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Jean B. Nachega
    • 1
    • 2
    • 3
    Email author
  • Olatunji Adetokunboh
    • 2
  • Olalekan A. Uthman
    • 2
    • 4
  • Amy W. Knowlton
    • 3
  • Frederick L. Altice
    • 5
  • Mauro Schechter
    • 6
  • Omar Galárraga
    • 7
  • Elvin Geng
    • 8
  • Karl Peltzer
    • 9
    • 10
    • 11
  • Larry W. Chang
    • 3
  • Gilles Van Cutsem
    • 12
  • Shabbar S. Jaffar
    • 13
  • Nathan Ford
    • 14
  • Claude A. Mellins
    • 15
  • Robert H. Remien
    • 16
  • Edward J. Mills
    • 17
  1. 1.University of Pittsburgh Graduate School of Public HealthPittsburghUSA
  2. 2.Stellenbosch University Faculty of Medicine and Health SciencesCape TownSouth Africa
  3. 3.Johns Hopkins UniversityBaltimoreUSA
  4. 4.Warwick Medical SchoolThe University of WarwickCoventryUK
  5. 5.Yale University School of Medicine and Public HealthYaleUSA
  6. 6.Projeto Praça OnzeRio de JaneiroBrazil
  7. 7.Brown University School of Public HealthProvidenceUSA
  8. 8.University of CaliforniaSan FranciscoUSA
  9. 9.Mahidol UniversitySalayaThailand
  10. 10.University of LimpopoPolokwaneSouth Africa
  11. 11.Human Sciences Research CouncilPretoriaSouth Africa
  12. 12.Médecins Sans FrontièresCape TownSouth Africa
  13. 13.Liverpool School of Tropical MedicineLiverpoolUK
  14. 14.World Health OrganizationGenevaSwitzerland
  15. 15.HIV Center for Clinical and Behavioral StudiesColumbia UniversityNew YorkUSA
  16. 16.New York State Psychiatric InstituteNew YorkUSA
  17. 17.Precision Global HealthVancouverCanada

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