title: 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.
abstract: 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.
authors.affiliation: University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA. jbn16@pitt.edu.|Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa. jbn16@pitt.edu.|Johns Hopkins University, Baltimore, MD, USA. jbn16@pitt.edu.
authors.forename: Jean B
authors.initials: JB
authors.lastname: Nachega
authors.affiliation: Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa.
authors.forename: Olatunji
authors.initials: O
authors.lastname: Adetokunboh
authors.affiliation: Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa.|Warwick Medical School, The University of Warwick, Coventry, UK.
authors.forename: Olalekan A
authors.initials: OA
authors.lastname: Uthman
authors.affiliation: Johns Hopkins University, Baltimore, MD, USA.
authors.forename: Amy W
authors.initials: AW
authors.lastname: Knowlton
authors.affiliation: Yale University School of Medicine and Public Health, Yale, CT, USA.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
authors.affiliation: Projeto Praça Onze, Rio de Janeiro, Brazil.
authors.forename: Mauro
authors.initials: M
authors.lastname: Schechter
authors.affiliation: Brown University School of Public Health, Providence, RI, USA.
authors.forename: Omar
authors.initials: O
authors.lastname: Galárraga
authors.affiliation: University of California, San Francisco, CA, USA.
authors.forename: Elvin
authors.initials: E
authors.lastname: Geng
authors.affiliation: Mahidol University, Salaya, Thailand.|University of Limpopo, Polokwane, South Africa.|Human Sciences Research Council, Pretoria, South Africa.
authors.forename: Karl
authors.initials: K
authors.lastname: Peltzer
authors.affiliation: Johns Hopkins University, Baltimore, MD, USA.
authors.forename: Larry W
authors.initials: LW
authors.lastname: Chang
authors.affiliation: Médecins Sans Frontières, Cape Town, South Africa.
authors.forename: Gilles
authors.initials: G
authors.lastname: Van Cutsem
authors.affiliation: Liverpool School of Tropical Medicine, Liverpool, UK.
authors.forename: Shabbar S
authors.initials: SS
authors.lastname: Jaffar
authors.affiliation: World Health Organization, Geneva, Switzerland.
authors.forename: Nathan
authors.initials: N
authors.lastname: Ford
authors.affiliation: HIV Center for Clinical and Behavioral Studies, Columbia University, New York, NY, USA.
authors.forename: Claude A
authors.initials: CA
authors.lastname: Mellins
authors.affiliation: New York State Psychiatric Institute, New York, NY, USA.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Remien
authors.affiliation: Precision Global Health, Vancouver, Canada.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Mills
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003151:Community Health Centers; D003430:Cross-Sectional Studies; D003906:Developing Countries; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006266:Health Education / Q000458:organization & administration*; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D064887:Observational Studies as Topic; D010352:Patient Dropouts / Q000706:statistics & numerical data; D016032:Randomized Controlled Trials as Topic; D000072230:Sustained Virologic Response; D014480:United Nations; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents
keywords: ART; Adherence; Community; Interventions; LMIC; Retention