title: Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries:  a systematic review and meta-analysis.
abstract: OBJECTIVE
  To estimate antiretroviral therapy (ART) adherence rates during pregnancy and postpartum in high-income, middle-income, and low-income countries.
  
  
  METHODS
  Systematic review and meta-analysis.
  
  
  METHODS
  MEDLINE, EMBASE, SCI Web of Science, NLM Gateway, and Google scholar databases were searched. We included all studies reporting adherence rates as a primary or secondary outcome among HIV-infected pregnant women. Two independent reviewers extracted data on adherence and study characteristics. A random-effects model was used to pool adherence rates; sensitivity, heterogeneity, and publication bias were assessed.
  
  
  RESULTS
  Of 72 eligible articles, 51 studies involving 20 153 HIV-infected pregnant women were included. Most studies were from United States (n =  14, 27%) followed by Kenya (n = 6, 12%), South Africa (n = 5, 10%), and Zambia (n = 5, 10%). The threshold defining good adherence to ART varied across studies (>80, >90, >95, 100%). A pooled analysis of all studies indicated a pooled estimate of 73.5% [95% confidence interval (CI) 69.3-77.5%] of pregnant women who had adequate (>80%) ART adherence. The pooled proportion of women with adequate adherence levels was higher during the antepartum (75.7%, 95% CI 71.5-79.7%) than during postpartum (53.0%, 95% CI 32.8-72.7%; P = 0.005). Selected reported barriers for nonadherence included physical, economic and emotional stresses, depression (especially postdelivery), alcohol or drug use, and ART dosing frequency or pill burden.
  
  
  CONCLUSIONS
  Our findings indicate that only 73.5% of pregnant women achieved optimal ART adherence. Reaching adequate ART adherence levels was a challenge in pregnancy, but especially during the postpartum period. Further research to investigate specific barriers and interventions to address them is urgently needed globally.
authors.affiliation: Department of International Health, Global Disease Epidemiology and Control Program, Johns Hopkins University Bloomberg School of Public Health, 615N. Wolfe Street, Suite W5031, Baltimore,MD21205, USA. jnachega@jhsph.edu
authors.forename: Jean B
authors.initials: JB
authors.lastname: Nachega
authors.forename: Olalekan A
authors.initials: OA
authors.lastname: Uthman
authors.forename: Jean
authors.initials: J
authors.lastname: Anderson
authors.forename: Karl
authors.initials: K
authors.lastname: Peltzer
authors.forename: Sarah
authors.initials: S
authors.lastname: Wampold
authors.forename: Mark F
authors.initials: MF
authors.lastname: Cotton
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Mills
authors.forename: Yuh-Shan
authors.initials: YS
authors.lastname: Ho
authors.forename: Jeffrey S A
authors.initials: JS
authors.lastname: Stringer
authors.forename: James A
authors.initials: JA
authors.lastname: McIntyre
authors.forename: Lynne M
authors.initials: LM
authors.lastname: Mofenson
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage* / Q000191:economics; D019049:Developed Countries / Q000191:economics*; D003906:Developing Countries / Q000191:economics*; D005260:Female; D006679:HIV Seropositivity / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008297:Male; D049590:Postpartum Period; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology; D012923:Social Class; D014481:United States / Q000453:epidemiology; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents