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Supportive interventions to improve retention on ART in people with HIV in low- and middle-income countries: A systematic review.

ABSTRACT: OBJECTIVES:To determine whether supportive interventions can increase retention in care for patients on antiretroviral therapy (ART) in low- and middle-income countries (LMIC). DESIGN:Systematic review and meta-analysis. METHODS:We used Cochrane Collaboration methods. We included randomised controlled trials (RCT) and observational studies with comparators conducted in LMIC. Our principal outcomes were retention, mortality and the combined outcome of lost-to-follow-up (LTFU) or death. RESULTS:We identified seven studies (published in nine articles); six of the studies were from Sub-Saharan Africa. We found four types of interventions: 1) directly observed therapy plus extra support ("DOT-plus"), 2) community-based adherence support, 3) adherence clubs and 4) extra care for patients with low CD4 count. One RCT of a community-based intervention showed significantly improved retention at 12 months (RR 1.14, 95% CI 1.02 to 1.27), and three observational studies found significantly improved retention for paediatric patients followed for 12 to 36 months (RR 1.07, 95 CI 1.03 to 1.11), and for adult patients at 12 (RR 1.38, 95% CI 1.13 to 1.70) and 60 months (RR 1.07, 95% CI 1.07 to 1.08). One observational study of adherence clubs showed significantly reduced LTFU or mortality (RR 0.20, 95% CI 0.12 to 0.33). A cluster RCT of an extra-care intervention for high-risk patients also showed a significant increase in retention (RR 1.06, 95% CI 1.01 to 1.10), and an observational study of extra nursing care found a significant decrease in LTFU or mortality (RR 0.76, 95% CI 0.66 to 0.87). CONCLUSIONS:Supportive interventions are associated with increased ART programme retention, but evidence quality is generally low to moderate. The data from this review suggest that programmes addressing psychosocial needs can significantly help retain patients in care.

SUBMITTER: Penn AW

PROVIDER: S-EPMC6294385 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Supportive interventions to improve retention on ART in people with HIV in low- and middle-income countries: A systematic review.

Penn Amy W AW Azman Hana H Horvath Hacsi H Taylor Kelly D KD Hickey Matthew D MD Rajan Jay J Negussie Eyerusalem K EK Doherty Margaret M Rutherford George W GW

PloS one 20181214 12

<h4>Objectives</h4>To determine whether supportive interventions can increase retention in care for patients on antiretroviral therapy (ART) in low- and middle-income countries (LMIC).<h4>Design</h4>Systematic review and meta-analysis.<h4>Methods</h4>We used Cochrane Collaboration methods. We included randomised controlled trials (RCT) and observational studies with comparators conducted in LMIC. Our principal outcomes were retention, mortality and the combined outcome of lost-to-follow-up (LTFU ...[more]

PMID: 30550574

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Project description:IntroductionSeveral approaches have been taken to reduce pre-antiretroviral therapy (ART) losses between HIV testing and ART initiation in low- and middle-income countries, but a systematic assessment of the evidence has not yet been undertaken. The aim of this systematic review is to assess the potential for interventions to improve or facilitate linkage to or retention in pre-ART care and initiation of ART in low- and middle-income settings.MethodsAn electronic search was conducted on Medline, Embase, Global Health, Web of Science and conference databases to identify studies describing interventions aimed at improving linkage to or retention in pre-ART care or initiation of ART. Additional searches were conducted to identify on-going trials on this topic, and experts in the field were contacted. An assessment of the risk of bias was conducted. Interventions were categorized according to key domains in the existing literature.ResultsA total of 11,129 potentially relevant citations were identified, of which 24 were eligible for inclusion, with the majority (n=21) from sub-Saharan Africa. In addition, 15 on-going trials were identified. The most common interventions described under key domains included: health system interventions (i.e. integration in the setting of antenatal care); patient convenience and accessibility (i.e. point-of-care CD4 count (POC) testing with immediate results, home-based ART initiation); behaviour interventions and peer support (i.e. improved communication, patient referral and education) and incentives (i.e. food support). Several interventions showed favourable outcomes: integration of care and peer supporters increased enrolment into HIV care, medical incentives increased pre-ART retention, POC CD4 testing and food incentives increased completion of ART eligibility screening and ART initiation. Most studies focused on the general adult patient population or pregnant women. The majority of published studies were observational cohort studies, subject to an unclear risk of bias.ConclusionsFindings suggest that streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives may decrease attrition, but the quality of the current evidence base is low. Few studies have investigated combined interventions, or assessed the impact of interventions across the HIV cascade. RESULTS from on-going trials investigating POC CD4 count testing, patient navigation, rapid ART initiation and mobile phone technology may fill the quality of evidence gap. Further high-quality studies on key population groups are required, with interventions informed by previously reported barriers to care.

Project description:BackgroundImproving health workers' performance is vital for achieving the Millennium Development Goals. In the literature on human resource management (HRM) interventions to improve health workers' performance in Low and Middle Income Countries (LMIC), hardly any attention has been paid to the question how HRM interventions might bring about outcomes and in which contexts. Such information is, however, critical to assess the transferability of results. Our aim was to explore if realist review of published primary research provides better insight into the functioning of HRM interventions in LMIC.MethodologyA realist review not only asks whether an intervention has shown to be effective, but also through which mechanisms an intervention produces outcomes and which contextual factors appear to be of critical influence. Forty-eight published studies were reviewed.ResultsThe results show that HRM interventions can improve health workers' performance, but that different contexts produce different outcomes. Critical implementation aspects were involvement of local authorities, communities and management; adaptation to the local situation; and active involvement of local staff to identify and implement solutions to problems. Mechanisms that triggered change were increased knowledge and skills, feeling obliged to change and health workers' motivation. Mechanisms to contribute to motivation were health workers' awareness of local problems and staff empowerment, gaining acceptance of new information and creating a sense of belonging and respect. In addition, staff was motivated by visible improvements in quality of care and salary supplements. Only a limited variety of HRM interventions have been evaluated in the health sector in LMIC. Assumptions underlying HRM interventions are usually not made explicit, hampering our understanding of how HRM interventions work.ConclusionApplication of a realist perspective allows identifying which HRM interventions might improve performance, under which circumstances, and for which groups of health workers. To be better able to contribute to an understanding of how HRM interventions could improve health workers' performance, a combination of qualitative and quantitative research methods would be needed and the use of common indicators for evaluation and a common reporting format would be required.

Project description:ObjectiveTo support evidence informed decision-making, we systematically examine the effectiveness and cost-effectiveness of community engagement interventions on routine childhood immunisation outcomes in low-income and middle-income countries (LMICs) and identify contextual, design and implementation features associated with effectiveness.DesignMixed-methods systematic review and meta-analysis.Data sources21 databases of academic and grey literature and 12 additional websites were searched in May 2019 and May 2020.Eligibility criteria for selecting studiesWe included experimental and quasi-experimental impact evaluations of community engagement interventions considering outcomes related to routine child immunisation in LMICs. No language, publication type, or date restrictions were imposed.Data extraction and synthesisTwo independent researchers extracted summary data from published reports and appraised quantitative risk of bias using adapted Cochrane tools. Random effects meta-analysis was used to examine effects on the primary outcome, full immunisation coverage.ResultsOur search identified over 43 000 studies and 61 were eligible for analysis. The average pooled effect of community engagement interventions on full immunisation coverage was standardised mean difference 0.14 (95% CI 0.06 to 0.23, I2=94.46). The most common source of risk to the quality of evidence (risk of bias) was outcome reporting bias: most studies used caregiver-reported measures of vaccinations received by a child in the absence or incompleteness of immunisation cards. Reasons consistently cited for intervention success include appropriate intervention design, including building in community engagement features; addressing common contextual barriers of immunisation and leveraging facilitators; and accounting for existing implementation constraints. The median intervention cost per treated child per vaccine dose (excluding the cost of vaccines) to increase absolute immunisation coverage by one percent was US$3.68.ConclusionCommunity engagement interventions are successful in improving outcomes related to routine child immunisation. The findings are robust to exclusion of studies assessed as high risk of bias.

Project description:IntroductionAddressing the intersection between mental health and HIV is critical for the wellbeing of persons living with HIV (PLWH). This systematic review synthesized the literature on mental health interventions for PLWH in low- and middle-income countries (LMICs) to determine intervention components and explore their relationship with intervention effectiveness.MethodsWe included only controlled clinical trials of interventions aiming to improve the mental health of PLWH. We conducted a search in the following databases: PubMed, CINAHL, PsycINFO and EMBASE for eligible studies describing the evaluation of interventions for mental health problems among PLWH in LMICs published through August 2020. Two reviewers independently screened references in two successive stages of title/abstract screening and then full-text screening for references meeting title/abstract criteria.ResultsWe identified a total of 30 eligible articles representing 6477 PLWH who were assigned to either the intervention arm (n = 3182) or control arm (n = 3346). The mental health interventions evaluated were psychological (n = 17, 56.67%), pharmacological (n = 6, 20.00%), combined psychological and pharmacological (n = 1, 3.33%) and complementary/alternative treatments (n = 6, 20.00%). The mental health problems targeted were depression (n = 22, 73.33 %), multiple psychological symptoms (n = 1, 3.33%), alcohol and substance use problems (n = 4, 13.33%), post-traumatic stress disorder (n = 1, 3.33%) and HIV-related neuro-cognitive impairment (n = 2, 6.67%). Studies of interventions with significant effects had significantly a higher number of active ingredients than those without significant effects [3.41 (2.24) vs. 1.84 (1.46) Mean (SD)] [Mean difference = -1.56, 95% CI = -3.03 to -0.09, p = 0.037].ConclusionsThere continue to be advances in mental health interventions for PLWH with mental illness in LMICs. However, more research is needed to elucidate how intervention components lead to intervention effectiveness. We recommend scale up of culturally appropriate interventions that have been successfully evaluated in low- and middle-income countries.

Project description:BackgroundDepression commonly co-exists with human immunodeficiency virus (HIV), but in low- and middle-income countries (LMICs), where the HIV burden is greatest, mental health resources are limited. These settings may benefit from psychosocial interventions delivered to people living with HIV/AIDS (PLWH) by non-mental health specialists. We aimed to systematically review randomised controlled trials (RCTs) that investigated the effectiveness of psychosocial interventions delivered by non-mental health specialists to prevent depression in PLWH in LMICs.MethodsWe used a comprehensive electronic search strategy to identify RCTs of any stage, including pilot studies, which reported on the effectiveness of a psychosocial intervention on depression among adults living with HIV/AIDS in a LMIC setting. Screening, study selection and data extraction was completed independently by two authors. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and performed a narrative synthesis.ResultsWe identified 3431 studies, from which we included 15 studies corresponding to 14 RCTs and a total of 3997 PLWH. Eleven studies were parallel RCTs, one was a stepped-wedged RCT, one was a full factorial RCT, one was a three-arm RCT and four were pilot studies. Studies were generally small, with eight including depression as a primary outcome. All but four trials included men and women and most studies followed participants for less than one year. Twelve trials had at least one domain in which there was a high risk of bias, with the remaining two trials having at least one domain of concern, due to lack of reporting of items. In 12 studies people in the intervention arm had statistically significantly (P < 0.05) lower or more reduced depressive symptom scores, or were less likely to have major depression, at final follow-up than people in the control group.ConclusionsPsychosocial interventions delivered by non-specialist mental health workers may be effective in preventing or reducing depression in PLWH in LMICs. However, existing studies are small with a relatively short follow-up period and have methodological limitations. Future trials should address these shortcomings, establish whether intervention effects are clinically meaningful and investigate cost-effectiveness.

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Supportive interventions to improve retention on ART in people with HIV in low- and middle-income countries: A systematic review.

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Supportive interventions to improve retention on ART in people with HIV in low- and middle-income countries: A systematic review.

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