Synthesizing Community-Based Treatment Supporter Interventions That Promote Antiretroviral Treatment Adherence Among Adults in East and Southern Africa: A Systematic Review

Background: Optimal adherence ART is key to achieving viral suppression, positive health outcomes among HIV patients. Poor adherence to ART is associated with treatment resistance, increased hospitalizations, and mortality. Community-based treatment supporter (CTS) programs are vital in enhancing sustained ART adherence. This review seeks to describe CTS interventions, assess the quality of the evidence of intervention studies and the effectiveness in improving ART adherence outcomes among people living with HIV/AIDS (PLWH) in East and Southern Africa (ESA). 

Methods: Study authors collaboratively developed search questions, inclusion and exclusion criteria for this review. A search strategy was identified and implemented following PRISMA protocols for systematic reviews. Electronic databases included: PubMed/MEDLINE, EMBASE, SCOPUS, The Web of Science, The Cochrane Library and ClinicalTrials.gov databases between the years 2003 and 2019. Studies were reviewed based on the following criteria: (1) conducted in ESA, (2) measured ART adherence outcomes, (3), had at least a pre-posttest design that describes a quantitative outcome of the intervention, (4) included adults aged 18 and above. Data extracted from eligible studies included study design, the host country, target population, intervention setting, and intervention components, types of supporters, ART adherence outcomes and ART adherence measures used. The quality of the studies was evaluated using the Methodological Quality Rating Scale (MQRS). An MQRS summary score for 14 items was used to rate studies ranging from 0 to 23 to establish the level of rigor in terms of high, medium and low.

Results: Of the 17 studies, ten are RCTs, and eight are quasi-experimental. Selected studies represent 76,132 patients in seven ESA: Uganda (n=7), South Africa (n=4), Rwanda (n=2). Kenya, Malawi, Mozambique, and Tanzania have one study each. For the methodological quality of studies, the mean MQRS rating was 15.9, the median score 16, and a range of 12-21. Most studies (n=9) scored equal or above the median (high rigor), while the rest (n=8) scored below the median (medium rigor). A notable methodological strength is that most studies (80%) used at least two different ART adherence measures, while 35% used three or more. Most studies measured ART adherence using CD4 cell count (n=10), and virologic suppression (n=9), while fewer studies used pill count (n=7), and self-report (n=6). Only one study used a medication monitoring system. CTS including partners, family members, trained community health workers, and HIV positive peers remained patients to take or refill their medication, conducted follow-up visits, home visits/care, psycho-social support, medication pickups, and referral to social services. CTS significantly improved optimal ART adherence reduced viral load and increased CD4) among HIV positive patients in most interventions (n=15).

Conclusion and implications:  In overburdened and resource-constrained public health settings, CTS interventions may promote and improve ART adherence. Although we found inconsistencies in measuring ART adherence across studies, the use of multiple ART adherence measures within studies added to methodological rigor. CTS are effective in addressing stigma against PLWH and may advance UNAIDS’ goal of 90% of PLWHA on ART and 90% of PLWH reporting viral suppression by 2030.