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J Int AIDS Soc. 2017 Mar 3;20(1):21218. doi: 10.7448/IAS.20.1.21218.

Adherence to antiretroviral therapy for HIV in sub-Saharan Africa and Asia: a comparative analysis of two regional cohorts.

Author information

1
Amsterdam Institute for Global Health and Development and Department of Global Health, Academic Medical Center of the University of Amsterdam, Amsterdam, The Netherlands.
2
The Kirby Institute, Biostatistics and Databases Program, UNSW Australia, Sydney, NSW, Australia.
3
Joint Clinical Research Centre, Kampala, Uganda.
4
Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
5
Lusaka Trust Hospital, Lusaka, Zambia.
6
HIV-NAT/Thai Red Cross AIDS Research Centre, Bangkok, Thailand.
7
College of Medicine, University of Lagos, Lagos, Nigeria.
8
Division of Infectious Diseases, Department of Medicine, Research Institute for Health Sciences, Chiang Mai, Thailand.
9
Infectious Disease Unit, Department of Medicine, Hospital Sungai Buloh, Sungai Buloh, Malaysia.
10
Research Institute for Tropical Medicine, Manila, Philippines.
11
TREAT Asia/amfAR, The Foundation for AIDS Research, Bangkok, Thailand.
12
Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center of the University of Amsterdam, Amsterdam, The Netherlands.

Abstract

INTRODUCTION:

Our understanding of how to achieve optimal long-term adherence to antiretroviral therapy (ART) in settings where the burden of HIV disease is highest remains limited. We compared levels and determinants of adherence over time between HIV-positive persons receiving ART who were enrolled in a bi-regional cohort in sub-Saharan Africa and Asia.

METHODS:

This multicentre prospective study of adults starting first-line ART assessed patient-reported adherence at follow-up clinic visits using a 30-day visual analogue scale. Determinants of suboptimal adherence (<95%) were assessed for six-month intervals, using generalized estimating equations multivariable logistic regression with multiple imputations. Region of residence (Africa vs. Asia) was assessed as a potential effect modifier.

RESULTS:

Of 13,001 adherence assessments in 3934 participants during the first 24 months of ART, 6.4% (837) were suboptimal, with 7.3% (619/8484) in the African cohort versus 4.8% (218/4517) in the Asian cohort (p < 0.001). In the African cohort, determinants of suboptimal adherence were male sex (odds ratio (OR) 1.27, 95% confidence interval (CI) 1.06-1.53; p = 0.009), younger age (OR 0.8 per 10 year increase; 0.8-0.9; p = 0.003), use of concomitant medication (OR 1.8, 1.0-3.2; p = 0.044) and attending a public facility (OR 1.3, 95% CI 1.1-1.7; p = 0.004). In the Asian cohort, adherence was higher in men who have sex with men (OR for suboptimal adherence 0.6, 95% CI 0.4-0.9; p = 0.029) and lower in injecting drug users (OR for suboptimal adherence 1.6, 95% CI 0.9-2.6; p = 0.075), compared to heterosexuals. Risk of suboptimal adherence decreased with longer ART duration in both regions. Participants in low- and lower-middle-income countries had a higher risk of suboptimal adherence (OR 1.6, 1.3-2.0; p < 0.001), compared to those in upper-middle or high-income countries. Suboptimal adherence was strongly associated with virological failure, in Africa (OR 5.8, 95% CI 4.3-7.7; p < 0.001) and Asia (OR 9.0, 95% CI 5.0-16.2; p < 0.001). Patient-reported adherence barriers among African participants included scheduling demands, drug stockouts, forgetfulness, sickness or adverse events, stigma or depression, regimen complexity and pill burden.

CONCLUSION:

Psychosocial factors and health system resources may explain regional differences. Adherence-enhancing interventions should address patient-reported barriers tailored to local settings, prioritizing the first years of ART.

KEYWORDS:

Asia; HIV-1; adherence; antiretroviral therapy (ART); sub-Saharan Africa

PMID:
28362063
PMCID:
PMC5467608
DOI:
10.7448/IAS.20.1.21218
[Indexed for MEDLINE]
Free PMC Article

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