Research Article: Comparison of Antiretroviral Therapy Adherence Among HIV-Infected Older Adults with Younger Adults in Africa: Systematic Review and Meta-analysis

Date Published: July 3, 2018

Publisher: Springer US

Author(s): Najeebullah Soomro, Grace Fitzgerald, Janet Seeley, Enid Schatz, Jean B. Nachega, Joel Negin.


As access to antiretroviral treatment in low- and middle-income countries improves, the number of older adults (aged ≥ 50 years) living with HIV is increasing. This study compares the adherence to antiretroviral treatment among older adults to that of younger adults living in Africa. We searched PubMed, Medline, Cochrane CENTRAL, CINAHL, Google Scholar and EMBASE for keywords (HIV, ART, compliance, adherence, age, Africa) on publications from 1st Jan 2000 to 1st March 2016. Eligible studies were pooled for meta-analysis using a random-effects model, with the odds ratio as the primary outcome. Twenty studies were included, among them were five randomised trials and five cohort studies. Overall, we pooled data for 148,819 individuals in two groups (older and younger adults) and found no significant difference in adherence between them [odds ratio (OR) 1.01; 95% CI 0.94–1.09]. Subgroup analyses of studies using medication possession ratio and clinician counts to measure adherence revealed higher proportions of older adults were adherent to medication regimens compared with younger adults (OR 1.06; 95% CI 1.02–1.11). Antiretroviral treatment adherence levels among older and younger adults in Africa are comparable. Further research is required to identify specific barriers to adherence in the aging HIV affected population in Africa which will help in development of interventions to improve their clinical outcomes and quality of life.

Partial Text

Globally, there are 36.7 million people living with human immunodeficiency virus (HIV), of which 69% live in Africa [1]. UNAIDS estimated that in 2016 there were 5.8 (5.3–6.2) million people aged 50 years and older living with HIV, representing 17% of all adults aged 15 years and over living with HIV [2]. Their modelling data also predicts that the number of older adults living with HIV in low- and middle-income countries around the world will increase by 47% by 2020 and most of them will be living in sub-Saharan Africa (SSA).

Our systematic review shows that ART adherence among older people is similar to that of younger people in SSA. Despite a general neglect of programs for older adults living with HIV in Africa and despite issues of poverty, social exclusion, lack of support and mobility challenges, adherence is not statistically different to that of younger people. A 2013 meta-analysis by Ghidei and colleagues identified 12 studies from non-African settings that contained data on older adult adherence compared to younger counterparts [7]. They found that older age reduced the risk of non-adherence by 27% in the studies from the US, Italy, United Kingdom, Canada and Brazil. Our study found no such difference in their adherence. However, this review included studies that used a variety of different measures of adherence each of which have their own strengths and weaknesses [40]. For example, self-report is a practical tool in low-resource settings, but can overestimate adherence [41]. Pharmacy refill adherence measures such as pill counts and calculation of the medication possession ratio can be impractical and do not measure whether patients are actually taking their medication, although are less prone to reporting bias than self-report [42, 43]. Clinical contact measures require a clinician to classify adherence as good or poor, and thus subject to assessment bias and difficult to standardize [43]. All three included measures have been demonstrated to be significantly predictive of detectable viremia [44].

This systematic review and meta- analysis found ART adherence levels were similar among older and younger adults in Africa. Further research might identify specific barriers to adherence in the HIV affected populations, and targeted interventions to improve clinical outcomes and quality of life when those affected by HIV grow older.




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