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Abstract

Dramatic increases in the evidence-base for intervention approaches to support antiretroviral therapy (ART) adherence have resulted in numerous reviews, syntheses, and guidelines/recommendations. This review characterizes the current state of the literature and identifies areas in need of additional targeted focus to better align research and practice. Leading recommendations for the process of intervention development (relevant to both rigorous research and real-world intervention planning) and strategies to consider in working with individuals, communities, and systems are provided. In order to move systematically toward the identification of what kinds of interventions work best for whom and when, attending to both intervention outcomes and “drivers” of observed effects or lack of effects in controlled research is critically important. Further, evidence emerging from practice should be aggressively added to research agendas to promote better synergies between the practice and research communities.

Keywords

HIV adherence intervention review practice-based evidence evidence-based practice

Introduction

Expanding HIV testing and heightened investment in treatment has dramatically increased the numbers of people living with HIV (PLWH) who have access to lifesaving antiretroviral (ARV) medication. Data from 2010 estimated that 34 million people were HIV positive and in low- and middle-income countries 6.65 million PLWH were on ARV medications.¹ While the personal health benefits of ARV medications are well recognized,² the effects of early treatment in averting HIV transmission is now an additional goal of treatment based on HPTN052’s reported 97% reduction in HIV-infection among partners of PLWH who initiated ARV treatment at CD counts of 550 cells/mm versus 250 cells/mm (the standard used at the time of the study).³ However, adherence insufficient to achieve viral suppression creates a gap between potential and the realized personal or public health benefits of ARV therapy.

Antiretroviral therapy (ART) adherence has been the focus of targeted attention since the wide-scale availability of ARVs and the “Achilles Heel” of treatment success.⁴ Early work in ART adherence clearly identified medication-related barriers to adherence where near perfect adherence was needed for regimens that were dosed 3 times daily and often had challenging side effects, including appearance of altering fat redistributions and persistent gastrointestinal discomfort.⁵ ^, ⁶ Advances in ARV therapy development have dramatically changed the tolerability of ART, and numerous first-line therapies are presently available that involve single co-formulated tablets and daily dosing. While regimen simplification is associated with higher adherence,⁷ ^, ⁸ adherence continues to challenge a sizable proportion of those on ART. In one evaluation, some 40% of those on ART do not achieve the recommended rates of ART use.⁹ A recent review of viral suppression outcomes among over 32 000 patients in the United States suggested that sustained viral suppression in those treated with ART improved from 45% in 2001 to 72% in 2010,¹⁰ likely attributable in part to increasing availability and use of simplified and tolerable regimens. Conversely, even with the improved regimens presently available, over a quarter of individuals treated failed to achieve sustained viral suppression.

Numerous factors extending beyond the characteristics of the patients and regimens influence adherence, giving rise to a diverse literature of health behavior models and behavioral and structural interventions to promote adherence and treatment success. Numerous health behavior models have been developed for or applied to ART adherence in efforts to understand the driving determinants of optimal and sustained use of ART.¹¹ These highlight the complexities of adherence as a self-directed time-indefinite personal and social behavior. Numerous intervention approaches have been developed and evaluated drawing from these and other models. Generally, interventions appear to be effective¹² ^, ¹³ but the diversity in approaches and outcomes in the published literature limits clear delineation of what discrete strategies work and, more importantly, what works best for who and when. Because recommendations for the use of interventions to support adherence are included in a number of treatment guidelines^14–16 with relatively sparse guidance on what to target or consider in approaches for intervention, we provide a brief overview of potential determinants of ART adherence and a summary of effective and promising approaches to promoting adherence and provide recommendations for both research and practice communities.

What to Address in Adherence Interventions?

In considering strategies to promote ART adherence, it is helpful to first identify the targets of a given intervention (what will be changed or supported in order to improve or sustain high rates of adherence) and then consider how to impact those targeted factors (specific intervention strategies or approaches). Obviously, the ultimate target is adherence and its persistence over time. Short of direct delivery and observation of each dose or the development of some delivery mechanism that bypasses self-directed dosing behaviors, interventions must work with the factors that lead to good adherence or the mitigation of factors that deter adherence. Thus, identifying what to target in an intervention precedes consideration of how to actually do this, and the extent to which targeted factor/factors actually relate to adherence in many ways sets the upper limit for ultimate efficacy of an intervention approach.

There are a number of discrete factors that have been associated with ART adherence. Across populations, these include accessibility of experience of side effects, availability of resources (including food, finances, and transport to HIV care), knowledge/literacy concerning the condition and its treatment, stability of daily schedule/routine, social support and stigma, positive and negative beliefs about medications, coping, depression, competing priorities and substance use, medication management skills, executive memory and cognitive functioning, simply “forgetting,” and consistent source for medications and use of them.^17–22 Arguably, these individual level correlates are contextualized by the social–cultural context of living with HIV and community-level beliefs more generally about medical establishments treating HIV. Further, with so many discrete correlates of adherence identified, higher order organization of these correlates into models of health behavior offers multiple benefits, such as allowing for more targeted intervention approaches and appropriately contextualizing individual behavior in the context of larger social, cultural, and structural systems.

Models of adherence that combine discrete correlates and situate individual behavior in larger contexts have been proposed and offer some guidance toward identifying common “drivers” of adherence. A basic taxonomy suggested in the late 1990s continues to provide a useful heuristic for considering determinants of adherence: aspects of the patient, aspects of the provider and patient–provider relationship, aspects of the regimen and illness, and the contextual (environmental, structural, community) factors that influence adherence.²³ Health behavior models typically draw from across these general areas to identify core factors that while housed within the individual are the net result of previous and ongoing interactions with others (important others, HIV care providing staff, communities) and with systems of care. While no single behavioral model has been identified as effective in predicting adherence (see for example the study by Amico et al¹¹), when considering intervention strategies the articulation of an underlying model is essential for identifying what to target (what aspects of the person, social interactions, system of care, or regimen should be addressed by the intervention) and why it would be expected to positively impact adherence. Across behavioral models, common critical determinants of adherence include knowledge, attitudes, beliefs, perceptions of benefits and costs, social support, past and current experiences with care providers, real and perceived burdens to adherence and several executive functions like developing skills, negotiation of behavior in common situations, coping, and regulation of perceived threats to health. Determinants of adherence likely have commonalities between cultures and geographies but also unique factors emerging from unique culture and community systems (see for example the work of Simoni et al¹⁹).

Behavioral models typically attempt to explain the behavior, whereas “how” to influence change on any of the identified core determinants of adherence requires additional consideration. Numerous models identifying strategies to promote change on the individual, community, and structural level are available (eg, motivational interviewing,²⁴ ^, ²⁵ cognitive behavioral therapy strategies,²⁶ peer delivery models,²⁷ community health workers (CHWs),²⁸ ^, ²⁹ or technology^30–33). In order to identify effective and not-effective strategies for promoting adherence, both the explanatory and the intervention delivery models adopted need to be identified. Failed intervention approaches may be ineffective because they did not change the targeted factor (eg, participants or patients did not develop new skills) or the intervention was effective in promoting change in the targeted factor, but the factor itself was not sufficiently or uniquely related to adherence for a given population (eg, new skills were developed but the development of new skills was not related to improved adherence). Additionally, the needs of a given population (eg, are rates of adherence currently suboptimal, are the barriers targeted by an intervention actual barriers in the study sample?) or lack thereof effects outcomes and must be carefully considered. Tremendous resources are allocated to rigorous research on approaches to adherence support. Whereas much of the literature currently available determines effects of a given intervention approach on the basis of intent to treat and additionally as treated, the identification of what the intervention changed or failed to change within what kind of cohort and whether success, or failure, can be attributable to one or more of these factors is less often included (see for example the study by de Bruin et al³⁴). However, we would argue that this level of granularity is essential to promoting systematic progress toward identifying strategies that are effective in promoting high and consistent adherence. At minimum, research should clearly articulate the targets of their interventions and present data relevant to the success of the intervention in influencing those targets; strategies adopted in practice should similarly identify what a strategy or approach addresses, why it would be expected to influence adherence in a given population, and monitor for success in influencing the targeted factors.

The process of identifying what explanatory models appear to be more reflective of adherence in a certain patient population and which delivery model would offer greatest benefit can involve substantial adaptation. Intervention mapping³⁵ offers a systematic process for intervention development that can provide guidance for this process with the advantages of producing clear delineation of what will be targeted for change or support and how. Adapting models developed to explain adherence predominantly for one population (eg, PLWH in the United States) to a different population (eg, PLWH in Uganda) can be guided by Ware et al’s³⁶ suggested process where 4 basic questions provide an evaluation of validity for a model: (1) Are the model concepts relevant to the new setting? (2) Are the concepts relevant in the new setting well represented in the model? (3) Do the definitions of the concepts in the model have accuracy in the new setting? and (4) Is the model comprehensive enough to explain the full complexity of adherence in the new setting? Intervention mapping and vetting model validity are both exercises that can benefit research and practice through re-focusing intervention efforts on specific populations and attending to the social–cultural context in which adherence is negotiated. The need for better articulation of the phenomenon of interest has been identified for some time (see for example the article by Bain-Brickley et al³⁷), but there continues to be a general lack of targeted efforts to evaluate the general strength and accuracy of the behavioral models that underlie intervention efforts.

Strategies and Approaches for Promoting ART Adherence

The literature pertaining to evaluation of comprehensive intervention packages has grown dramatically over the past decade. In 2003, Simoni and colleagues³⁸ summarized adherence interventions evaluated through January 2003, identifying only 4 studies with sufficient rigor in randomized controlled trials (RCTs) to provide evaluation of the intervention approach. Only 3 years later, 2 meta analyses included 16 RCTs¹³ and 24 within-group studies and RCTs¹² providing sufficient data to determine effect of adherence. Updated through 2007, the pool of qualifying within-group and RCT studies increased to 48³⁹ with other reviews also noting the sharp increase in adherence intervention–focused literature (13 new intervention studies from September 2007 to October 2009⁴⁰). Reflecting this expanding evidence base, multiple reviews have provided insights specific to certain aspects of research, including distilling effects of quality adherence support and within special populations.

A meta-analysis focused on determining the relationship of implementation of strategies that quantified standard care quality and success (undetectable viral load) provided a novel way of evaluating effects of different kinds of adherence support in 13 different studies meeting criteria for inclusion in these analyses.⁴¹ Across these, activities targeting adherence were classified into 7 basic targets (or determinants); activities targeting knowledge, awareness of general and individual-specific rates of adherence and nonadherence, attitudes, self-efficacy, intentions, action control (eg, reminder strategies, adherence plans), and general facilitation (eg, side effects management, home delivery of medication, regimen simplification). Within each target area, the authors identified a number of discrete techniques or strategies used in the evidence base of available interventions, each associated with a specific score. Total scores across these strategies determined the overall quality score which was associated with undetectable viral load. These findings are particularly interesting in that care quality, across intervention and control conditions, related to virologic success, calling to attention the need to consider intervention outcomes as relative to what the standard of care control condition had available in terms of adherence support.

Focusing on intervention approaches implemented with PLWH in sub-Saharan Africa through January 2011, Barnighausen and colleagues⁴² reviewed 26 studies, concluding that numerous intervention approaches, including the use of diary cards, food rations, treatment supporters, and text messaging, have received support. These authors recommended that strategies leveraged to address barriers to adherence need to be linked specifically to the resources and resource limitations of a given patient population. Reviewing studies using directly observed therapy (DOT) there have been conflicting results, with Ford and colleagues⁴³ suggesting nonsignificant overall effects (12 studies through July 2009) and Hart and colleagues⁴⁴ found DOT participants within group and RCT trials to have significant gains in viral load, CD4, and adherence (17 studies through August 2009) although these gains were nonsignificant when restricted to only RCTs. Reviewing only studies using CHWs in the United States, Kenya and colleagues²⁹ concluded the these intervention strategies using over 24 weeks of CHW contact and medication management appeared to be successful in improving adherence and reducing viral load (16 studies from May 2010 to November 2010). Rueda and colleagues’⁴⁵ Cochran review of 19 RCTs similarly identified medication management skills as particularly promising as an approach for the general clinic population. These authors also suggested that intervention delivered over 12 weeks or more and working with individuals versus groups may be more effective.

Systematic reviews of interventions are also available for youth and pediatric adherence,^46–48 adherence during pregnancy,⁴⁹ methamphetamine using men who have sex with men,⁵⁰ and other populations. Increasingly, syntheses of studies using specific intervention delivery approaches are emerging, with several reviews currently available for DOT and use of CHWs, as noted above, as well as contingency management,⁵⁴ motivational interviewing-based interventions,²⁴ mobile phone text messaging,³⁰ ^, ³¹ and cognitive behavioral interventions.⁵⁵ Accessing these reviews and the separate studies they draw from are important first steps in identifying unmet needs and the relative success of various intervention approaches within a special population or cohort.

National and international guidelines also provide general and specific suggestions for practice communities. International guidelines recently released⁵³ provide a number of recommendations for strategies found to be effective in the evidence-graded literature concerning adherence monitoring and support approaches, as well as for linkage and retention in HIV care. Specific to ART adherence support and promotion, these recommendations include provision of basic adherence tools (reminder and organization devices) and individual education and counseling, and offering group counseling, multidisciplinary support, and peer support. Each recommendation is graded for its quality of evidence (methodological rigor and strength of outcomes in the evidence base) and strength of recommendation in terms of scope of recommended strategy (does the recommendation apply to all, most, or some patients). Special populations, including pregnant women, substance abusers, those with comorbid mental health conditions, incarcerated individuals, homeless, and children and adolescents, have recommendations specific to work, targeting these groups. While monitoring and support ART adherence has long been included as a part of guidelines for providing ART, these guidelines are the first to offer concrete recommendations for how to do so.

Recommended processes to generate targeted adherence support and specific approaches culled from the literature are offered in Tables 1 and 2, respectively. We note that the sources provided in Table 1 are not intended to be exhaustive, nor are all recommendations, syntheses, or guidelines included. The recommendations are frequently encountered in the literature as well as in research and practice discussion groups. Many of these recommendations are straight forward and relatively inexpensive in terms of resources to implement. In addition to discrete strategies for support, the Centers for Disease Control's (CDC's) evidence-based interventions (EBIs) have recently been expanded to include a chapter on ART adherence interventions (http://www.cdc.gov/hiv/topics/research/prs/ma-chapter.htm). This compendium draws from peer-reviewed literature to identify interventions that meet criteria for best or good evidence specifically for work conducted in the United States or a US territory. Identified interventions are then “packaged” so that agencies can use the intervention approach in full. Manuals and technical assistance facilitate this process. Presently, there are 8 interventions identified as having “good” evidence, with no intervention meeting “best” evidence criteria. Good interventions include the use of nurse-delivered home visits,⁵⁷ couples-based counseling,⁵⁸ individual and group counseling,⁵⁹ ^, ⁶⁰ peer support,⁶¹ and 2-way texting.⁶¹ Additionally 2 DOT interventions specifically evaluated with drug-using populations are identified as “good.”⁶² ^, ⁶³ Intervention package information for any of these interventions was listed as not yet available as of early 2012.

Bridging Research and Practice: Adding Practice-based Evidence to the Equation

As can be seen from Tables 1 and 2, recommendations that have substantial “face validity” and intuitive appeal are not necessarily well supported by an established research base, predominantly due to a lack of evaluation versus evaluations that demonstrate null findings. Similarly, using a parachute when jumping from a plane lacks an evidence base and nonetheless is a well-adopted, arguably effective, practice.⁶⁴ While effects of behavioral intervention certainly lack such dramatic or definitive outcomes as use and nonuse of a parachute, the recognition that not all successful strategies are those identified and demonstrated in rigorous research trials is important. It is well recognized that in practice patient needs for adherence support do not go unmet while we wait for sufficient research guidance. Rather, clinics and care providers innovate based on available resources and knowledge to develop strategies, individual and systems level, to support patient populations. de Bruin’s⁴¹ work suggests that practices adopted in “standard of care” comparison arms in RCTs can have equally, even more, effective adherence approaches than the intervention condition. Recent work evaluating standard of care practices for ART and retention in care support suggests that a number of approaches are in place to meet patient needs in most clinical care centers.⁷¹ Whereas evidence-based practice largely has been defined as a process in which research identifies effective support approaches and practice then adopts them, an alternative way of conceptualizing the collaboration of research and practice is to use research methods to evaluate the interventions already in place in practice (practice-based evidence).

Table 1.

Designing Intervention Processes.

Area	Strategy/Recommendation	Source(s)
Process	Design intervention approach based on feedback from stakeholders and experts in intervention design, identify pathways (intervention to outcomes for desired effects and on impact on health system and subsystems), adapt approach to maximize system-wide positive effects and minimize negative effects and evaluate design with indicators of effects and planned timeline for analyses and revision (budget and funding plans included)	51
Process	When applying or adapting models (extended to interventions for adherence) confirm that (1) the model's concepts are relevant to a given setting; (2) factors important in setting are in the model; (3) basic concepts are accurate (valid) to setting; (4) the model captures the full dynamics of adherence in setting.	36
Process	Intervention strategies should be evaluated in terms of cost-Effectiveness, Usefulness (from stakeholders' and patients' perspective), Realistic in terms of implementation, use Robust components (multiple modalities and ways to provide support), Evolve over time (flexibility to adjust over time and in response to experience), and are Sustainable (CURRES)	52
Process	Intervention approaches should evolve from and progress with 5 steps: (1) identify factors that need to be addressed, improved, or sustained; (2) use a model (theory) to organize the factors that influence those factors (identify intervention targets); (3) select theory-based and practical strategies to intervene on targets; (4) develop a method for disseminating the intervention(s); (5) monitor implementation and outcomes	35,53

Table 2.

Strategies to Promote ART Adherence from Published Reviews, Syntheses, and Guidelines.^a

Area	Recommendation	Reviews and Guidelines
General	Assess factors that influence adherence/assess barriers and suggest strategies to overcome them	14,15,41,65; (14: assess before and when on ART); (41: quality care factor—determine causes of nonadherence, promote general strategies to address barriers)
General	Implement targeted interventions (address barriers; problem-solving support)	38,40,65,66
General	Support development and use of discrete specific skills (over general messaging on importance of or need for perfect adherence)	66
General	Provide one-on-one adherence support through one or more counseling approaches	56
General	Provide group education/group counseling support in a format and to cover content relevant to a specific patient population	Adapted from (56)
General	Target and enhance self-efficacy for adherence	38
General	Assess and address common misconceptions and cultural beliefs regarding ART	66
General	Review and adopt an evidence-based intervention package (eg, CDC's EBI)	14
General	Mobilize community support	16,42,67
Engagement	Invite patients to actively contribute to care and treatment planning	14,38,40,68
Engagement	Facilitate positive interactions at point of care (positive patient–provider relationships)	14,38,66
Access	Ensure consistent access to ART medications	42,67
Monitor	Monitor levels of adherence	14,38,40,65 –68; (14: assess adherence at every clinical visit)
Monitor	Presence of adverse events when starting ART and over time	67
Monitor	Collect self-report data and medication refill data routinely (pill counts, drug concentration, and electronic drug monitoring not recommended for routine use in practice)	14,56
Monitor	Ask about adherence at each clinical visit using open-ended questions (Please tell me how you took your medications over the last 3 days)	14
Monitor	Identify type of nonadherence (prescription refill, timing/quantity, or food requirement/special instructions nonadherence)	14
Monitor with feedback	Collect adherence data and use to provide targeted feedback	40,41; (41: quality adherence care factor—electronic drug monitoring)
Monitor with feedback	Collect and feedback CD4 and viral load	41; (41: quality adherence care factor)
Regimen	Simplify regimen—effective once-daily or coformulated regimens are preferred	14,56,67 (14: US DHS—simplify regimen when possible)
Education	Explain the regimen	38,40,41,56,68; (41: quality adherence care factor); (56: IAAC guidelines include one-on-one education)
Education	Use of material (figures, pictures, so on) to promote transfer of information and promote memory and understanding	15,41,56; (15: SA DOH—creative use of media); (42: quality adherence care factor); (56: IAPAC guidelines include one-on-one education using adult learning principles)
Education	Explain role of adherence, consequences on nonadherence, and resistance	40,41,56,66; (41: listed as quality adherence care factor—information and persuasive messaging on importance of adherence); (56: IAPAC guidelines include one-on-one education)
Education	Provide brochure or written information (general and specific to one's regimen for when to take what)	41; (41: listed as quality adherence care factor)
Education/Skills	Discuss side effects and management	15,38,40,41,66; (41: listed as quality adherence care factor—education and management of); (56: IAPAC guidelines include one-on-one education)
Navigation	Link to services; treat concomitant conditions	14,38,40,41,66,68,69; (41: listed as quality adherence care factor—link to social work)
Navigation for unmet needs	Offer case management and resources for food insecurity, housing, and transportation	15,42,56; (15: SA DOH—food insecurity)
Patient-centered care	Adopt regimens that are tailored to patient's lifestyle and as "simple" as possible	38,41,68; (41: listed as quality adherence care factor)
Patient-centered care	Establish readiness for antiretroviral therapy (ART) before prescribing	14,40,56
Patient-centered care	Use multidisciplinary treatment team approaches to consolidate treatment of multiple conditions and use of combined services	14,56,66,70; (56: IAPAC guidelines recommend coordination of disciplines in supporting adherence); (70: WHO TB/HIV treatment guidelines—consolidate HIV and TB treatment)
Patient-centered care	Avoid judgmental or punishing interactions in discussing and reacting to nonadherence	15,66; (15: SA DOH—reduce judgmental attitudes)
Patient-centered care	Adopt neutral stance in discussion of adherence (avoid overly enthusiastic or overly negative reactions to reported adherence)	40
Patient-centered care	Support maintenance of high rates of adherence	40,66
Patient-centered care	Encourage patient accessing clinic if and when questions arise via phone contact	41; (41: listed as quality adherence care factor)
Patient-centered care	Ask about experiences with taking ART and refrain from "solving" or fixing reported barriers; allow patients to tell you their strategies	40
Patient-centered care	Avoid leading and closed questions about adherence (You are taking all you meds right?)	40
Patient-centered care	Follow-up with adherence plans or difficulties with adherence between appointments (eg, via phone)	41; (41: listed as quality adherence care factor)
Patient-centered care	Deliver medications to home	41; (41: listed as quality adherence care factor)
Patient-centered care	Increase resources of care through task shifting so that more ART prescribers are available	56
Patient-centered care	Establish a care team that is accessible and is perceived as trusted (establish trusting relationships with patients)	14,69
Social	Support development of social support/enlist support of those in social networks	38,40,41,42,66; (41: listed as quality adherence care factor)
Social	Facilitate connections with peers who are on ART	40,56; (56: IAPAC guidelines include consideration of offering peer support where available)
Social	Facilitate sharing among long-term ART users about their experiences (enlist collaborations with CBOs and the community)	40
Social (persuasion)	Encourage adherence (communication and messages delivered to support adherence)	41; (41: listed as quality adherence care factor)
Tools	Reminder devices	38,56,66
Tools	Communication technologies (interactive text messaging)	15,56; (15: SA DOH—use messaging systems)
Tools	Encourage use of pillboxes, diaries, cell phone alarms as needed and as adjuncts to other adherence support strategies	14,15,40,41,56,66; [41: listed as quality adherence care factor—7-day pillbox, alarms); (56: IAPAC guidelines- pillboxes with homeless populations); (15: SA DOH—use reminders)
Skills	Plan ahead for changes in routine, weekends, and holidays	38,41,68; (41: listed as quality adherence care factor)
Skills	Establish a routine; plan dose taking around routine, daily events, and cues; develop medication-taking schedules	38,41,56,68; (41: listed as quality adherence care factor); (56: IAPAC guidelines include integration of medication management into pharmacy systems)
Skills	Recommend storing/carrying extra dose/doses	41; (41: listed as quality adherence care factor)
Targeted intervention	Increase intensity of intervention and follow-up for those struggling with adherence	41; (41: listed as quality adherence care factor)
Targeted intervention	Tailor intervention approaches to stage of ART use (prior to initiation, initiation, and long-term use)	40
Targeted intervention	Incorporate routine HIV testing amongst expecting mothers and provision of ART for PTMTCT	56
Targeted intervention	Treat comorbid conditions—opiod-dependent patients on ART should be offered methadone or buprenorphine as part of comprehensive care; screen and treat for mental health conditions such as depression as part of routine care	15,56; (15: SA DOH—monitor/treat depression, alcohol abuse)
Targeted intervention	Offer directly observed therapy for substance using populations (independently or in conjunction with methadone maintenance) and for incarcerated individuals; DAART is not recommended for general population	56

Abbreviations: CBOs, community-based organizations; CDC, Centers for Disease Control; EBI, evidence-based interventions; SA, South Africa; DOH, Department of Health; IAPAC, International Association of Physicians in AIDS Care; US DHS, United State Department of Human Services; DAART, directly administered ART.

^a The sources referenced are examples and do not represent all guidelines, reviews, and syntheses including the specified recommendation.

The call to expand the focus of behavioral intervention research to include the vital process of adopting and implementing evidence-based strategies and to develop methodologies for evaluating practice-based strategies is not new.^72–75 However, guidelines and strategies for equipping practice and research communities with the resources and technical expertise to develop a practice-driven evidence base are generally lacking. Processes such as intervention mapping³⁵ ^, ⁵³ or systems thinking⁵¹ offer steps to constructing, applying, and evaluating intervention approaches leveraged in practice that may be very useful in these endeavors. Over the next decade, a better characterization of standard of care for adherence, and retention in HIV care, in diverse regions and with diverse patient groups would be beneficial in directing research agendas. Redefining collaborations between research and practice to aggressively establish a practice-driven evidence base could have dramatic effects on consolidating resources and synergizing areas of expertise.

Conclusions

The evidence base for effective adherence support interventions generally supports behavioral approaches but effects are modest and the need for greater specificity to identify “what works best for whom and when” is becoming increasingly possible as the availability of research and practice-based evidence expands. Adherence support strategies that emphasize patient-centered and responsive care systems are included across multiple reviews and guidelines, as are approaches that promote positive experiences with care providers and building medication management skills. There is a paucity of research focused on implementation science and practice-based evidence, which are both needed to bridge science and practice most efficiently. As recommendations for specific strategies and packaged approaches have clearly emerged in the recent literature, monitoring the implementation of these in real-world practice is critical to setting a coordinated agenda for both the research and practice. In order to move systematically toward the identification of what kinds of interventions work best for who and when, attending to both intervention outcomes and drivers of observed effects or lack of effects in controlled research is critically important. Further, evidence emerging from practice should be aggressively added to research agendas to promote better synergies between the practice and research communities.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Antiretroviral Therapy Adherence Support

Abstract

Keywords

Introduction

What to Address in Adherence Interventions?

Strategies and Approaches for Promoting ART Adherence

Bridging Research and Practice: Adding Practice-based Evidence to the Equation

Conclusions

Footnotes

Declaration of Conflicting Interests

Funding

References