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Viral Load Monitoring as a Tool to Reinforce Adherence: A Systematic Review

Bonner, Kimberly MPA*; Mezochow, Alyssa MSc*; Roberts, Teri PhD, MNutr*; Ford, Nathan PhD, MPH*,†; Cohn, Jennifer MD, MPH*

JAIDS Journal of Acquired Immune Deficiency Syndromes: September 1st, 2013 - Volume 64 - Issue 1 - p 74–78
doi: 10.1097/QAI.0b013e31829f05ac
Brief Report: Clinical Science

Objective: Viral load monitoring has been proposed as a tool to reinforce adherence, but outcomes have never been systematically assessed.

Design: A meta-analysis was conducted to systematically analyze the research on viral load monitoring as a tool to reinforce adherence. Viremic resuppression is defined here as a decrease in viral load beneath a particular threshold following viral load levels that have been elevated despite antiretroviral treatment.

Methods: Six databases were searched for studies published up to November 2012, which reported the use of viral load monitoring as a tool to identify patients in need of adherence support. Three conference abstract sites were reviewed for studies reported in the last 2 years. Randomized and quasi-randomized trials and observational studies, were eligible. No language or geographical restrictions were applied.

Results: Six retrospective and 2 prospective observational studies reported data from 8 countries: South Africa, the United States, Thailand, Mali, Burkina Faso, Swaziland, India, and France. Five studies reported on viremic resuppression, with a pooled estimate of 70.5% (95% confidence interval: 56.6% to 84.4%) resuppressed. The remaining 3 studies all reported declines in mean viral load. Delayed onset of routine viral load monitoring was associated with the emergence of drug resistance.

Conclusions: The clear trend of resuppression, following viral load testing and adherence support, demonstrates the utility of viral load as a tool to identify patients in need of enhanced adherence support.

Supplemental Digital Content is Available in the Text.

*Access Campaign, Médecins Sans Frontières, Geneva, Switzerland; and

Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa.

Correspondence to: Kimberly Bonner, MPA, MSF Access Campaign, Médecins Sans Frontières, Rue de Lausanne 78, P.O Box 116, CH-1211 Geneva 21, Switzerland (e-mail:

K.B. and A.M. contributed equally to this manuscript.

The authors have no funding or conflicts of interest to disclose.

N.F. conceived and designed the review, conducted the meta-analysis, and provided critical feedback; A.M. acquired articles, conducted full text searches, data abstraction, and drafted the article; K.B. conducted title and abstract search and full text searches, data abstraction, and drafted the article; T.R. provided critical edits; and J.C. provided substantial design support and edits to the manuscript.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Received February 28, 2013

Accepted June 01, 2013

© 2013 by Lippincott Williams & Wilkins