title: Patient-Reported Barriers to Adherence to Antiretroviral Therapy: A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  Maintaining high levels of adherence to antiretroviral therapy (ART) is a challenge across settings and populations. Understanding the relative importance of different barriers to adherence will help inform the targeting of different interventions and future research priorities.
  
  
  RESULTS
  We searched MEDLINE via PubMed, Embase, Web of Science, and PsychINFO from 01 January 1997 to 31 March 2016 for studies reporting barriers to adherence to ART. We calculated pooled proportions of reported barriers to adherence per age group (adults, adolescents, and children). We included data from 125 studies that provided information about adherence barriers for 17,061 adults, 1,099 children, and 856 adolescents. We assessed differences according to geographical location and level of economic development. The most frequently reported individual barriers included forgetting (adults 41.4%, 95% CI 37.3%-45.4%; adolescents 63.1%, 95% CI 46.3%-80.0%; children/caregivers 29.2%, 95% CI 20.1%-38.4%), being away from home (adults 30.4%, 95% CI 25.5%-35.2%; adolescents 40.7%, 95% CI 25.7%-55.6%; children/caregivers 18.5%, 95% CI 10.3%-26.8%), and a change to daily routine (adults 28.0%, 95% CI 20.9%-35.0%; adolescents 32.4%, 95% CI 0%-75.0%; children/caregivers 26.3%, 95% CI 15.3%-37.4%). Depression was reported as a barrier to adherence by more than 15% of patients across all age categories (adults 15.5%, 95% CI 12.8%-18.3%; adolescents 25.7%, 95% CI 17.7%-33.6%; children 15.1%, 95% CI 3.9%-26.3%), while alcohol/substance misuse was commonly reported by adults (12.9%, 95% CI 9.7%-16.1%) and adolescents (28.8%, 95% CI 11.8%-45.8%). Secrecy/stigma was a commonly cited barrier to adherence, reported by more than 10% of adults and children across all regions (adults 13.6%, 95% CI 11.9%-15.3%; children/caregivers 22.3%, 95% CI 10.2%-34.5%). Among adults, feeling sick (15.9%, 95% CI 13.0%-18.8%) was a more commonly cited barrier to adherence than feeling well (9.3%, 95% CI 7.2%-11.4%). Health service-related barriers, including distance to clinic (adults 17.5%, 95% CI 13.0%-21.9%) and stock outs (adults 16.1%, 95% CI 11.7%-20.4%), were also frequently reported. Limitations of this review relate to the fact that included studies differed in approaches to assessing adherence barriers and included variable durations of follow up. Studies that report self-reported adherence will likely underestimate the frequency of non-adherence. For children, barriers were mainly reported by caregivers, which may not correspond to the most important barriers faced by children.
  
  
  CONCLUSIONS
  Patients on ART face multiple barriers to adherence, and no single intervention will be sufficient to ensure that high levels of adherence to treatment and virological suppression are sustained. For maximum efficacy, health providers should consider a more triaged approach that first identifies patients at risk of poor adherence and then seeks to establish the support that is needed to overcome the most important barriers to adherence.
authors.affiliation: Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom.
authors.forename: Zara
authors.identifier: http://orcid.org/0000-0002-7102-1867
authors.initials: Z
authors.lastname: Shubber
authors.affiliation: Precision Global Health, Vancouver, Canada.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Mills
authors.affiliation: Department of Epidemiology, Infectious Diseases and Microbiology, University of Pittsburgh, Graduate School of Public Health Pittsburgh, Pennsylvania, United States of America.|Department of Medicine and Centre for Infectious Diseases, Stellenbosch University, Cape Town, South Africa.|Department of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Jean B
authors.initials: JB
authors.lastname: Nachega
authors.affiliation: Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, United States of America.|Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
authors.forename: Rachel
authors.identifier: http://orcid.org/0000-0001-5460-8204
authors.initials: R
authors.lastname: Vreeman
authors.affiliation: Department of HIV/AIDS, Ministry of Health, Brasilia, Brazil.
authors.forename: Marcelo
authors.identifier: http://orcid.org/0000-0002-0763-233X
authors.initials: M
authors.lastname: Freitas
authors.affiliation: Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa.
authors.forename: Peter
authors.identifier: http://orcid.org/0000-0003-3211-6078
authors.initials: P
authors.lastname: Bock
authors.affiliation: HIV, STI, and Other Blood Borne Infections Division, Rwanda Biomedical Centre, Ministry of Health, Rwanda.|University of Basel, Swiss Tropical and Public Health Institute, and Institute for Clinical Epidemiology and Biostatistics, Basel, Switzerland.
authors.forename: Sabin
authors.initials: S
authors.lastname: Nsanzimana
authors.affiliation: Department of HIV, World Health Organization, Geneva, Switzerland.
authors.forename: Martina
authors.initials: M
authors.lastname: Penazzato
authors.affiliation: AIDS and TB Unit, Ministry of Health and Child Welfare, Harare, Zimbabwe.
authors.forename: Tsitsi
authors.initials: T
authors.lastname: Appolo
authors.affiliation: Department of HIV, World Health Organization, Geneva, Switzerland.
authors.forename: Meg
authors.identifier: http://orcid.org/0000-0003-2986-7129
authors.initials: M
authors.lastname: Doherty
authors.affiliation: Department of HIV, World Health Organization, Geneva, Switzerland.|Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.
authors.forename: Nathan
authors.initials: N
authors.lastname: Ford
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D019049:Developed Countries / Q000706:statistics & numerical data; D003906:Developing Countries / Q000706:statistics & numerical data; D015658:HIV Infections / Q000188:drug therapy* / Q000517:prevention & control* / Q000523:psychology; D015497:HIV-1 / Q000502:physiology; D006801:Humans; D055118:Medication Adherence / Q000523:psychology*; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents