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Adherence to Antiretroviral Therapy: Africa vs. North America

A meta-analysis of adherence studies yielded a pooled estimate of 77% adequate adherence in Africa versus 55% in North America.

Among HIV-infected individuals, sustained adherence to antiretroviral regimens is necessary, both to ensure treatment effectiveness and to slow the development and spread of drug resistance. Concern has been raised that adherence might be poor in Africa, where much of the population lives in poverty and has little formal education.

To determine whether this concern is justified, researchers performed a meta-analysis of studies that evaluated adherence to antiretroviral medications among heterogeneous populations in sub-Saharan Africa (27 studies totaling 12,116 patients) and North America (31 studies totaling 17,573 patients). Self-reports of adherence were utilized in 71% of the studies at North American sites and 66% of those at African sites. "Adequate adherence" was defined as meeting the study-specific adherence threshold, which ranged from 100% to >80%.

When all studies were included, pooled analyses showed adequate adherence in 55% of the patients in North America and 77% of those in Africa (P<0.001). Significantly better adherence in Africa than in North America was observed in comparisons of studies using adherence thresholds of 100% (P=0.004) and >95% (P<0.001), but not for studies with thresholds of >90% (P=0.41) or >80% (P=0.15). The adjusted odds ratio for adequate adherence in Africa compared with that in North America, independent of adherence threshold, was 2.5 (95% confidence interval, 1.9–3.3).

Comment: This analysis is hampered by dependence on self-reported adherence rates, lack of information about specific regimens (which are generally simpler in Africa than in North America), and lack of correlation with clinical and laboratory status. Also, most people currently treated at African sites are seeking out treatment on their own. Therefore, they may be a more self-motivated group than the North American treatment population, many of whom are now identified for treatment by the healthcare system rather than by themselves. Still, this study provides useful insights. First, it underscores the need for more data on the merits of intense monitoring (e.g., directly observed therapy) in achieving and sustaining clinical benefit. Second, as the authors note, it refutes the assumption that adherence to antiretroviral therapy will be inadequate in Africa — an assumption sometimes used to justify not expanding treatment programs on that continent.

— Keith Henry, MD

Published in AIDS Clinical Care September 1, 2006

Citation(s):

Mills EJ et al. Adherence to antiretroviral therapy in sub-Saharan Africa and North America: A meta-analysis. JAMA 2006 Aug 9; 296:679-90.

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