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A Systematic Review of Pediatric Adherence to Antiretroviral Therapy in Low- and Middle-Income Countries

Vreeman, Rachel C. MD, MS§; Wiehe, Sarah E. MD, MPH*†; Pearce, Emily C. MD*; Nyandiko, Winstone M. MbChB, MMed‡§

The Pediatric Infectious Disease Journal: August 2008 - Volume 27 - Issue 8 - p 686-691
doi: 10.1097/INF.0b013e31816dd325
Original Studies

Background: Sustaining antiretroviral therapy (ART) adherence requires accurate, consistent monitoring, a particular challenge for low-income countries. The optimal strategy to measure pediatric adherence remains unclear.

Objective: To conduct a systematic review of pediatric ART adherence measurement techniques, adherence estimates, and clinical correlates in low- and middle-income countries to inform ART adherence monitoring.

Methods: We searched online bibliographic databases, including MEDLINE and EMBASE, using systematic criteria. Two reviewers selected all descriptive or interventional studies involving nonpregnant, HIV-positive individuals ≤18 years old that measured ART adherence in low- or middle-income countries as defined by World Bank criteria. Data were extracted regarding sample characteristics, study setting, measurement strategy, adherence estimate, and adherence correlates.

Results: The search yielded 1566 titles, of which 17 met selection criteria. Adherence measurement strategies included self- or proxy-report measures (14 studies), pill counts (4 studies), pharmacy records, drug levels, clinic adherence, and directly observed therapy (1 study each). The self- or proxy-report measures were heterogeneous, and few employed validation strategies. Caregiver-reported adherence was generally higher than self-report estimates. Pill counts revealed lower adherence estimates. Estimates of ART adherence ranged from 49% to 100%, with 76% of articles reporting >75% adherence. Factors related to family structure, socioeconomic status, disclosure, and medication regimen were all significantly associated with ART adherence.

Conclusions: Pediatric HIV care programs in low- and middle-income countries use heterogeneous methods to measure ART adherence. Adherence estimates vary substantially, but most studies from low- and middle-income countries report >75% adherence, whereas most studies from high-income countries report <75% adherence.

From the *Children's Health Services Research, Indiana University School of Medicine; †The Regenstrief Institute for Health Care, Indianapolis, IN; ‡Department of Child Health and Paediatrics, Moi University School of Medicine; and §USAID—Academic Model for the Prevention and Treatment of HIV/AIDS (AMPATH) Partnership, Eldoret, Kenya.

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Accepted for publication February 14, 2008.

Supported in part by a grant to the USAID-AMPATH Partnership from the United States Agency for International Development as part of the President's Emergency Plan for AIDS Relief (PEPFAR).

The views expressed in this article are those of the authors and do not necessarily represent the view of the Indiana University School of Medicine or the Moi University School of Medicine.

The primary author had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Address for correspondence: Rachel C. Vreeman, MD, Children's Health Services Research, Health Information and Translational Sciences, Suite #1020, 410 W. 10th St., Indianapolis, IN 46202. E-mail:


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© 2008 Lippincott Williams & Wilkins, Inc.