Research Article

Adherence to HAART: A Systematic Review of Developed and Developing Nation Patient-Reported Barriers and Facilitators

  • Edward J Mills mail,

    To whom correspondence should be addressed. E-mail:

    Affiliation: Centre for International Health and Human Rights Studies, Toronto, Ontario, Canada

  • Jean B Nachega,

    Affiliations: Centre for International Health and Human Rights Studies, Toronto, Ontario, Canada, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

  • David R Bangsberg,

    Affiliation: San Francisco General Hospital, AIDS Division, University of California San Francisco, San Francisco, California, United States of America

  • Sonal Singh,

    Affiliations: Centre for International Health and Human Rights Studies, Toronto, Ontario, Canada, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

  • Beth Rachlis,

    Affiliation: BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, British Columbia, Canada

  • Ping Wu,

    Affiliation: Canadian College of Naturopathic Medicine, North York, Ontario, Canada

  • Kumanan Wilson,

    Affiliations: Centre for International Health and Human Rights Studies, Toronto, Ontario, Canada, Department of Medicine, University of Toronto, Toronto, Ontario, Canada

  • Iain Buchan,

    Affiliation: Evidence for Population Health Unit, University of Manchester, Manchester, United Kingdom

  • Christopher J Gill,

    Affiliation: Center for International Health and Development, Boston University School of Public Health, Boston, Massachusetts, United States of America

  • Curtis Cooper

    Affiliations: Centre for International Health and Human Rights Studies, Toronto, Ontario, Canada, Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada

  • Published: November 21, 2006
  • DOI: 10.1371/journal.pmed.0030438

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Highly Active Antiretroviral Therapy Adherence in Children: Outcomes from Africa

Posted by plosmedicine on 31 Mar 2009 at 00:10 GMT

Author: Anand Reddi
Position: No occupation was given
Institution: No affiliation was given
Additional Authors: Sarah C. Leeper
Submitted Date: June 25, 2007
Published Date: June 26, 2007
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Reports have confirmed the clinical efficacy and feasibility of highly active antiretroviral therapy (HAART) in adult HIV patients in Africa [1]. Additionally, despite international concern that “antiretroviral anarchy” due to poor adherence was eminent in resource limited settings [2], data cited by Amir Attaran in PLoS Medicine indicates that “Africans take HAART more faithfully than North Americans [3,4,5].” Attaran notes “Using the customary definition that ‘good adherence’ means taking HAART as prescribed 95% of the time or more, 82% of Africans succeeded at that goal, compared with only 55% of North Americans (p less than 0.001).”

Preliminary studies suggest that higher rates of HAART adherence in the developing world hold true even for pediatric patients. Our group at Sinikithemba HIV/AIDS clinic in South Africa recently documented the experience of 151 children who initiated HAART [6]. Eight-nine percent of our cohort reported over 95% adherence resulting in 84.0% and 80.3% virologic suppression (50 or more copies/ml HIV RNA) at 6 and 12 months, respectively [6]. Similarly , Eley in South Africa and Wamalwa et al. in Kenya report higher rates of HAART adherence and virologic suppression in children than found in the developed world [7,8]; In contrast, pediatric cohorts from the United States and Europe globally reported lower virologic efficacy ranging from 25-50% [9] attributed in part to lower adherence.

Is the difference in virologic suppression between African and western pediatric cohorts due to varying adherence rates or to other factors such as differences in patient populations, viral subtypes, HAART regimens, etc? Perhaps all of the above - at this time, the data lends itself only to guarded and heavily qualified interpretation. Future systematic meta studies similar to Mills et al [4,5], that focus on African pediatric adherence should be encouraged. These studies may well conclude definitively that African children’s adherence to HAART is higher than their western peers, and responsible for increased therapeutic response.

These apparent higher rates of HAART adherence in African cohorts have been the source of much theorizing from within the HIV research community. Attaran hypothesizes “To live in Nairobi means to face so many privations compared to New York that to overcome them and excel seems almost storybook untrue. But privation can cut both ways. People who have been denied the necessities of life, who then receive the gift of medicines and a chance to live, may be more likely to appreciate HAART [3].”

While not disputing that privation/increased valuation of HAART has some effect on improved patient adherence and outcomes, we believe there are larger (and, more importantly) other manipulable forces at play. In the Sinikithemba cohort, although half of the children are cared for by at least one HIV-positive caregiver, these caregivers showed a protective effect against pediatric mortality when compared with caregivers who were untested or HIV negative [6]. We hypothesized that HIV positive caregivers on HAART at the same treatment site may be able to provide more informed treatment support for their children resulting in better outcomes [6]. This suggests an important paradigm shift in the way we think about families infected with HIV: instead of families "ravaged" or "devastated" perhaps we might consider that if given access to treatment through a family-centered model, those on treatment can instead be sources of unity, continuity, knowledge, and strength for pediatric patients and other HIV-infected family members. We advocate for family centered HAART treatment models in order to protect the integrity of caregiving structures and prevent the negative pediatric outcomes associated with the decline in health or death of primary caregivers [6].


1. Akileswaran C, Lurie MN, Flanigan TP, Mayer KH (2005) Lessons learned from use of highly active antiretroviral therapy in Africa. Clin Infect Dis 41: 376-385.

2. Harries AD, Nyangulu DS, Hargreaves NJ, Kaluwa O, Salaniponi FM (2001) Preventing antiretroviral anarchy in sub-Saharan Africa. Lancet 358: 410-414.

3. Attaran A (2007) Adherence to HAART: Africans take medicines more faithfully than North Americans. PLoS Med 4: e83.

4. Mills EJ, Nachega JB, Bangsberg DR, Singh S, Rachlis B, et al. (2006) Adherence to HAART: a systematic review of developed and developing nation patient-reported barriers and facilitators. PLoS Med 3: e438.

5. Mills EJ, Nachega JB, Buchan I, Orbinski J, Attaran A, et al. (2006) Adherence to antiretroviral therapy in sub-Saharan Africa and North America: a meta-analysis. JAMA 296: 679-690.

6. Reddi A, Leeper SC, Grobler AC, Geddes R, France KH, et al. (2007) Preliminary outcomes of a paediatric highly active antiretroviral therapy cohort from KwaZulu-Natal, South Africa. BMC Pediatr 7: 13.

7. Eley B (2006) Addressing the paediatric HIV epidemic: a perspective from the Western Cape Region of South Africa. Trans R Soc Trop Med Hyg 100: 19-23.

8. Wamalwa DC, Farquhar C, Obimbo EM, Selig S, Mbori-Ngacha DA, et al. (2007) Early Response to Highly Active Antiretroviral Therapy in HIV-1-Infected Kenyan Children. J Acquir Immune Defic Syndr.

9. van Rossum AM, Fraaij PL, de Groot R (2002) Efficacy of highly active antiretroviral therapy in HIV-1 infected children. Lancet Infect Dis 2: 93-102.

No competing interests declared.