JAIDS Journal of Acquired Immune Deficiency Syndromes:
The article by Hart et al, appearing in JAIDS: Journal of Acquired Immune Deficiency Syndromes, Vol 54, No. 2, pp. 167-179 entitled “Effect of Directly Observed Therapy for Highly Active Antiretroviral Therapy on Virologic, Immunologic, and Adherence Outcomes: A Meta-Analysis and Systematic Review,” contains corrected results which are now being reported. Firstly, the authors conducted their meta-analysis with incorrect numbers for the virologic outcomes for Arnsten et al.'s randomized clinical trial. In the published manuscript, they reported a significant pooled effect of DOT-HAART on virologic suppression, with a random effects (RE) risk ratio of 1.24 (95% CI of 1.08, 1.41). The correct pooled effect on virologic outcomes is a RE risk ratio of 1.29, with a 95% CI of 1.12, 1.48 (see Figure). Meta-regression analysis (shown in the Table) also yields different results for the following stratifications: intervention effect on virologic suppression is now significant for interventions carried out in methadone clinics (RE risk ratio 1.87, 95% CI 1.61, 2.16) and for those DOT-HAART studies which were randomized controlled trials (RE risk ratio of 1.26, 95% CI 1.04, 1.52). DOT-HAART impact for several subcategories was already reported to be significant, but now demonstrates stronger intervention effect: enhanced DOT-HAART interventions, those conducted in resource-rich settings, interventions targeting HAART-experienced patients, and those for substance users.
Upon stratification, intervention effect among RCTs now reaches significance, whereas results in the prior report were of marginal significance (risk ratio of 1.18, 95% CI 0.99, 1.42). Perhaps most importantly, these corrected findings further strengthen the argument that DOT-HAART is an effective intervention for high-risk populations, particularly substance users and HAART-experienced individuals. Furthermore, the design of the intervention is likely an important determinant of effectiveness: both enhanced DOT (i.e. DOT-HAART delivered with additional “wrap-around” services”) and DOT delivered at a place of convenience for the client, such as a methadone clinic, reflect a philosophy of comprehensive patient-centered care, likely a key “ingredient” of effective DOT-HAART programs.
1. Hart JE, Jeon CY, Ivers LC, et al. Effect of directly observed therapy for highly active antiretroviral therapy on virologic, immunologic, and adherence outcomes: a meta-analysis and systematic review. J Acquir Immune Defic Syndr. 2010;54(2):167-179.
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