9.2 Guidance on operations and service delivery: adherence to ART
Consolidated ARV guidelines, June 2013
9.2.2 Interventions to optimize adherence to ART (part 1)
No single adherence intervention or package of interventions is effective for all populations and all settings. People’s needs and circumstances may also change over time, and programmes and care providers therefore need to tailor a combination of feasible interventions to maximize adherence to ART based on individual barriers and opportunities.
Programme-level interventions for improving adherence to ART include: (1) avoiding imposing out-of-pocket payments at the point of care, (2) using fixed-dose combination regimens for ART and (3) strengthening drug supply management systems to reliably forecast, procure, and deliver ARV drugs and prevent stock-outs.
The individual-level adherence intervention recommendation in this section relates to the use of mobile phone text messages. There have been simple and robust trials to demonstrate its importance as one of many adherence tools. Adherence interventions, such as text messaging, should clearly be provided as part of a total package of several interventions. Many individual level adherence interventions are indicated for reasons in addition to improving adherence to ART. For example, nutritional support, peer support, management of depression and substance use disorders and patient education are vital components of routine health and HIV care.
Efforts to support and maximize adherence should begin before ART is initiated. Developing an adherence plan and education are important first steps. Initial patient education should cover basic information about HIV, the ARV drugs themselves, expected adverse effects, preparing for treatment and adherence to ART. Adherence preparation should not delay treatment initiation, when prompt action is necessary.
Patient education and counselling and peer support
Patient education and counselling are essential both when ART is initiated and throughout the course of treatment. Informing and encouraging people receiving ART and their families and peers are essential components of chronic HIV care. Studies show that counselling improves adherence to ART, and in some settings there is an association between peer support and high rates of adherence and retention (18–23).
Substance use and mental health interventions
Studies indicate that improving well-being by treating depression and managing substance use disorders improves HIV treatment outcomes. The systematic review identified very low quality evidence from one observational study evaluating opioid substitution therapy for improving adherence. After 12 months, the rates of unsuppressed viral loads were comparable among people who inject drugs using opioid substitution therapy and people who inject drugs without opioid substitution therapy (24).
The systematic review also identified very-low-quality evidence from one randomized trial evaluating the treatment of depression for improving adherence. After 12 months, the risk of non-adherence was similar among those who received depression treatment and those who did not (25). WHO recommends co-treatment of depression and substance use disorders irrespective of HIV status, and concurrent treatment should be evaluated in relation to adherence to ART. Other services for people living with HIV who use drugs, such as needle and syringe programmes, drug dependence treatment and peer outreach, provide opportunities for supporting treatment adherence.
Nutrition assessment, care and support are essential components of HIV care. HIV programmes should ensure that existing national policies on nutritional support are observed when it is necessary and feasible to maximize adherence to ART and achieve optimal health outcomes in food-insecure settings.
Nutritional support could include nutritional counselling, cash transfers and subsidizing food costs and/or food vouchers. ART in conjunction with nutritional support could accelerate recovery. The systematic review identified one study from low- and middle-income countries with low-quality evidence showing that nutritional support provided by community health workers to people receiving ART reduces the risk of non-adherence after one year among food-insecure individuals relative to the standard of care (26).
Financial support may include reimbursement for the costs of receiving HIV care (including drugs, diagnostics, clinical services and transport vouchers) and may potentially mitigate the burden of HIV in disadvantaged settings. The systematic review identified very-low-quality evidence that financial support reduces the risk of non-adherence one year post-intervention relative to the standard of care (27).
Programmes and care providers should consider a broader programmatic approach for reducing the costs of care for people living with HIV that would include avoiding out-of-pocket payments at the point of care, decentralizing and coordinating care and exploring opportunities to minimize health facility visits. Programmes need to consider ethical implications and equity in providing food and financial support or other similar interventions for people living with HIV and not others. Standardized criteria for supporting people receiving ART may need to be developed based on national poverty levels.