Pregunta-problema a Investigar

Demographic characteristics such as gender, age, marital status, religion, and ethnicity have been inconsistent predictors of adherence across studies. Being male has been significantly

associated with both optimal [115, 116] and suboptimal adherence [117-120]. Maqutu et

al. [116] reported that the rate of adherence was significantly higher in males than in females at the beginning of follow-up, but this difference disappeared at the end of the 17th months (17th _{follow-up visit). Several other studies [121-127] did not find an association} between gender and adherence to ART.

Increasing age was associated with better adherence in all studies that found age as a significant predictor of adherence [115, 126, 128-132]. For instance, being aged 18-24, 25-

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34 and 35-44 vs. 44 (OR=2.00, 95% CI=1.05-3.83; OR=2.51, 95% CI=1.50-4.20; OR=2.06,

95% CI=1.28-3.30, respectively) were independently associated with higher odds of 30-day non-adherence [126]. Studies have reported a lack of association between marital status [115, 117, 119-122, 126, 131, 133-138], ethnicity [121, 135, 139], and religion [115, 117, 121, 138-140] with adherence.

Socioeconomic status, as indicated by education, employment status, income, food insecurity and transport costs, has been shown to influence adherence to ART in sub- Saharan Africa. Most of the studies that evaluated the level of education have not found an association with adherence [117-120, 122, 126, 131, 136, 139-145]. Those studies that had reported significant association found inconsistent relationships. Eholie et al. [125] reported that attaining secondary school education or above was associated with suboptimal adherence. No schooling was related to optimal adherence to ART among HIV- positive patients in South Africa [116]. A study in a Nairobi slum on patients taking on ART found a low level of education as an independent predictor of suboptimal adherence. This study reported that 62% of patients achieved optimal adherence [135].

Six studies reported no significant relationship between employment status and adherence to ART [117, 120, 129, 139, 142, 145]. Significant but inconsistent relationships were reported for unemployment in two studies; being unemployed was associated with suboptimal adherence in a survey of 253 Nigerian HIV-positive patients who had been on ART for a minimum of 6 months [115] while unemployment was related to optimal adherence in Cameroonian HIV-positive patients [140]. Several studies have assessed the relationship between income and adherence, but only one study found a significant

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association. Low income was predictive of suboptimal adherence in treatment naïve Cameroonian HIV-positive patients initiated on ART [118].

Findings have also been inconsistent in describing the association between adherence and food insecurity. Berhe et al. [141] reported that malnutrition was about 10 times more frequent in Ethiopian patients with suboptimal adherence. Food insecurity independently predicted suboptimal adherence in Congolese patients taking ART [145]. On the contrary, Sasaki et al. [119] reported experiencing food insufficiency in the past 30 days was associated with optimal adherence. This might be due to the greater social support focusing on people living in extreme poverty.

Psychological problems are related to suboptimal adherence in HIV-positive patients taking ART. A high level of depression was related to suboptimal adherence in all studies that reported depression as a significant predictor of adherence [124, 143, 146-150]. Do et al. [124] found that the presence of depression in Botswanan patients taking ART was associated with suboptimal adherence. Nakimuli-Mpungu et al. [142] reported that psychological distress (depression and anxiety) and living alone were independent predictors of suboptimal adherence in Ugandan HIV-positive patients.

Thirteen studies [124, 126, 129, 133, 140, 146, 147] reported a negative association between adherence to ART and alcohol use or disorders. Jaquet et al. [133] reported that alcohol consumption was significantly associated with lower adherence in HIV-positive patients in Western Africa. Etienne et al. [146] reported that alcohol use in the last month was predictive of poor adherence in HIV-infected patients from five different sub-Saharan Africa countries.

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Social supports that may involve emotional and material support for patients taking ART play a significant role in improving adherence. Consistent significant findings define the positive relationship between social support and adherence [128, 149, 151]. Diabate et al. [128] reported that absence of social support was related to suboptimal adherence. Peltzer et al. [149] found that a higher social support score was associated with achieving optimal adherence. Tiyou et al. [152] found that family support was related to better overall adherence (dose, time, and food). Encouraging patients to disclose their HIV status to family and friends, who can provide social support, facilitates medication taking.

Disclosure of HIV status relates to adherence to ART. Two studies reported that failure to disclose HIV status decreased adherence to ART [124, 135]. Do et al. [124] reported that failure to disclose one’s HIV-1 status to a partner was predictive of suboptimal adherence. Unge et al. [135] found that not disclosing HIV status (OR=4.7, 95% CI=1.78-12.43) was significantly associated with dose adherence of < 95%. Five studies [119, 129, 137, 145, 153] did not find an association between disclosure of HIV status and adherence. Some patients may not disclose their HIV status due to fear of stigma and discrimination. Stigma and discrimination were barriers to adherence to ART in sub-Saharan HIV-positive patients [147, 154]. Dlamini et al. [154] reported that perceived stigma was significantly associated with self-reported missed medications.

The use of memory aids such as mobile phone text-message reminders and pill boxes facilitate adherence to ART [144, 151]. Studies trialling the effect of mobile phone text- message reminders in sub-Saharan African HIV-positive patients found a significant improvement in adherence in the intervention group [155, 156].

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Patients’ baseline clinical parameters such as WHO or Centers for Disease Control and Prevention (CDC) clinical stage of HIV/AIDS, CD4 count, viral load, and weight did not predict adherence in several sub-Saharan African studies [116, 118, 121, 125, 127, 136, 137, 139, 149, 152, 153, 157]. Significant but inconsistent relationships were found

between adherence and baseline CD4 count in two studies. CD4 count 250 cells/µL was

associated with lower adherence in Western Africa HIV-positive patients [128] while CD4 count < 350 cells/µL was related to poor adherence in Ethiopian HIV-infected patients [141]. Berhe et al. [141] reported that having a baseline BMI < 18.5 kg/m2 _{was associated} with poor adherence to ART.