Adherence in antiretroviral therapy: a review of qualitative studies

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IntroductionSince the introduction of HAART, HIV- and AIDS-related mortality has declined tremendously [1,2]. The continuous, lifelong treatment with antiretroviral therapy has significantly improved life expectancy and turned HIV from a terminal infection into a chronic disease. In HAART, adherence is of utmost importance. Poor adherence, indeed, may lead to medication failure, viral mutations and development of drug resistance [3,4]. Future treatment options become limited because of cross-resistance [5]. The risk of transmission of resistant viruses makes adherence a public health concern [6,7]. Research and daily practice have shown that strict adherence is difficult to achieve for many of the HIV-infected patients treated with antiretroviral therapy [8,9]. Adherence to HAART requires patients to behave in a way that cannot easily be incorporated into daily life.On the basis of earlier studies on adherence, a level of 95% or more seems to be required to prevent the development of resistant viruses [10–12]. In more recent studies, it has been shown that durable viral suppression can be achieved by using HAART regimens that require lower adherence than 95% [13,14]. Other studies suggest that the relationship between adherence and the development of resistance differs by drug class. The prevalence of resistance to non-nucleoside reverse transcriptase inhibitors is significantly higher at low levels of adherence than that to protease inhibitors [15,16].To attain the benefits of HAART, there is a strong need for effective adherence interventions in the care of HIV-infected patients. In the process of developing patient-tailored intervention procedures, a literature study was carried out to examine what is known about the problem from the patient's perspective [17]. This article reports the results of this review.Quantitative studies identify factors related to or predicting adherence. Three reviews of these studies have been published in recent years [18–20]. The present review focuses on qualitative studies. Qualitative studies are conducted to explore the meaning people give to situations and are helpful in laying bare the processes that are at play in adherence [21]. To develop an intervention tailored to the individual situation, it is necessary to understand the way people manage their daily lives when taking HAART and the interaction of this process with adherence [17,22].Before discussing the findings from the qualitative studies, those of the quantitative reviews are summarized. The factors are grouped into the same dimensions and reported in the same sequence as used by the World Health Organization [20]: socioeconomic factors, healthcare team and system-related factors, condition-related factors, therapy-related factors and patient-related factors. Against this background, the findings of our own review are reported.Summary of factors related to adherence derived in quantitative studiesSocioeconomic factors such as age, gender, race, educational level and income level are inconsistent in influencing adherence [18,19]. Women who live together with children tend to have a lower level of adherence. [19]. Social support from family and friends affects adherence positively [18,20].Healthcare team and system-related factors related to adherence include clear instructions, providing adequate knowledge about the relationship between adherence and resistance and better medical follow-up. Support from nurses and pharmacists positively influences adherence [19]. However, Ammassari et al.[18] concluded that satisfaction with healthcare and the patient–provider relationship are inconsistent factors in affecting adherence.Condition-related factors such as CD4 cell count, viral load and time living with HIV do not significantly correlate with non-adherence in all studies [18,19]. Having HIV-related symptoms is positively associated with non-adherence [18].Therapy-related factors are seen as significantly associated with non-adherence [18,19].

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