Sustaining antiretroviral therapy (ART) adherence requires accurate and consistent monitoring, a particular challenge for low-income countries. The optimal strategy on how to measure pediatric adherence remains unclear. Vreeman and coworkers conducted a systematic review of pediatric ART adherence measurement techniques, adherence estimates, and clinical correlates in low- and middle-income countries to determine ART adherence. The investigators 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 or less 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. The search yielded 1,566 titles, 17 of which 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 greater than 75% adherence. Factors related to family structure, socioeconomic status, disclosure, and medication regimen were all significantly associated with ART adherence.

VALUE OF STUDY TO YOU AS A HEALTH CARE PROVIDER: 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 greater than 75% adherence, whereas most studies from high-income countries report less than 75% adherence.

VALUE OF STUDY TO YOU AS A PATIENT: This was an impressive study in that it showed that pediatric patients in developing countries use a variety of techniques to attain adherence that is better than that found in developed countries. As the rate of adherence worldwide generally hovers around 50% across studies, it suggests that patients and their health care providers are doing a better job of complying with medication instructions, at least with respect to HIV, than might have been predicted. The techniques used in developing countries to improve adherence deserve greater scrutiny.

RC Vreeman et al. A Systematic Review of Pediatric Adherence to Antiretroviral Therapy in Low- and Middle-Income Countries. Pediatric Infectious Disease Journal, June 19, 2008.