Interventions to improve antiretroviral therapy adherence among adolescents in low- and middle-income countries: A systematic review of the literature

Introduction Globally, an estimated 30% of new HIV infections occur among adolescents (15–24 years), most of whom reside in sub-Saharan Africa. Moreover, HIV-related mortality increased by 50% between 2005 and 2012 for adolescents 10–19 years while it decreased by 30% for all other age groups. Efforts to achieve and maintain optimal adherence to antiretroviral therapy are essential to ensuring viral suppression, good long-term health outcomes, and survival for young people. Evidence-based strategies to improve adherence among adolescents living with HIV are therefore a critical part of the response to the epidemic. Methods We conducted a systematic review of the peer-reviewed and grey literature published between 2010 and 2015 to identify interventions designed to improve antiretroviral adherence among adults and adolescents in low- and middle-income countries. We systematically searched PubMed, Web of Science, Popline, the AIDSFree Resource Library, and the USAID Development Experience Clearinghouse to identify relevant publications and used the NIH NHLBI Quality Assessment Tools to assess the quality and risk of bias of each study. Results and discussion We identified 52 peer-reviewed journal articles describing 51 distinct interventions out of a total of 13,429 potentially relevant publications. Forty-three interventions were conducted among adults, six included adults and adolescents, and two were conducted among adolescents only. All studies were conducted in low- and middle-income countries, most of these (n = 32) in sub-Saharan Africa. Individual or group adherence counseling (n = 12), mobile health (mHealth) interventions (n = 13), and community- and home-based care (n = 12) were the most common types of interventions reported. Methodological challenges plagued many studies, limiting the strength of the available evidence. However, task shifting, community-based adherence support, mHealth platforms, and group adherence counseling emerged as strategies used in adult populations that show promise for adaptation and testing among adolescents. Conclusions Despite the sizeable body of evidence for adults, few studies were high quality and no single intervention strategy stood out as definitively warranting adaptation for adolescents. Among adolescents, current evidence is both sparse and lacking in its quality. These findings highlight a pressing need to develop and test targeted intervention strategies to improve adherence among this high-priority population.


Introduction
Globally, an estimated 30% of new HIV infections occur among adolescents (15-24 years), most of whom reside in sub-Saharan Africa. Moreover, HIV-related mortality increased by 50% between 2005 and 2012 for adolescents 10-19 years while it decreased by 30% for all other age groups. Efforts to achieve and maintain optimal adherence to antiretroviral therapy are essential to ensuring viral suppression, good long-term health outcomes, and survival for young people. Evidence-based strategies to improve adherence among adolescents living with HIV are therefore a critical part of the response to the epidemic.

Methods
We conducted a systematic review of the peer-reviewed and grey literature published between 2010 and 2015 to identify interventions designed to improve antiretroviral adherence among adults and adolescents in low-and middle-income countries. We systematically searched PubMed, Web of Science, Popline, the AIDSFree Resource Library, and the USAID Development Experience Clearinghouse to identify relevant publications and used the NIH NHLBI Quality Assessment Tools to assess the quality and risk of bias of each study.

Results and discussion
We identified 52 peer-reviewed journal articles describing 51 distinct interventions out of a total of 13,429 potentially relevant publications. Forty-three interventions were conducted among adults, six included adults and adolescents, and two were conducted among adolescents only. All studies were conducted in low-and middle-income countries, most of these (n = 32) in sub-Saharan Africa. Individual or group adherence counseling (n = 12), mobile health (mHealth) interventions (n = 13), and community-and home-based care (n = 12) were the most common types of interventions reported. Methodological challenges plagued PLOS  Introduction effectiveness of adherence interventions for the general population [25][26][27][28][29][30][31][32][33][34], few have focused specifically on ALHIV in LMIC and none to date have included literature from adult populations to propose ALHIV-specific recommendations.
(n = 1), and depression treatment (n = 1). Interventions for combined adult and adolescent study populations included adherence counseling (n = 2), community-based adherence support (n = 2), and short message service (SMS) reminders (n = 1). Both studies conducted with adolescents evaluated group adherence counseling interventions. Adherence was measured using varied methods. Biological measures included CD4 counts, ART concentrations in hair samples, and viral load. Viral load measures included viral suppression using cut-offs of <50, <100, <200, or <400 copies/mL; and virologic failure with  Group counseling Adherence educational and/or counseling interventions delivered in a group setting. Includes social support groups. Sessions are often led by trained professionals or lay counsellors and delivered through a set curriculum or informed by a psychosocial theory/practice.

IVR or phone calls for reminders
Interactive voice response or regular phone calls delivering messages on medication adherence and other HIV/ART related topics, as well as appointment reminders. Some also sent non-interactive, SMS picture messages to remind patients of dosage adherence.

CBAS with home visits
Provision of adherence support through home visits by a community-based worker or volunteer. Home visitors can range from peer educators to community health workers. They are involved in a variety of activity such as DOT, basic clinical assessments and patient referrals, pill counts, food ration provision, and ART delivery. Community-based social network support Support at the community level designed to be delivered to a group. Includes interventions involving a patient's extended social network in that patient's treatment. 0 0 1 1

Pharmacist Counseling
Pharmacist counseling Shifting patient counseling to occur when patients receive their medication. Counseling was provided by pharmacist and drugrelated problems were addressed at each scheduled meeting. cut-offs of >40, >400 or >5,000 copies/mL. Pill counts were conducted by clinic staff or lay health workers and measured the number of pills remaining compared to the number of doses that should have been taken over a specified time period. Similarly, EAMDs such as MEMSCap TM or Wisepill TM measured whether and when patients opened pill bottles for each medication. Selfreported measures included the Adult AIDS Clinical Trial Group (AACTG) self-report measure [42], the Antiretroviral General Adherence Scale (AGAS) [43], the Pediatric AIDS Clinical Trials Group (PACTG) self-report measure [44,45], and Visual Analog Scales (VAS) [46]. The 52 studies presented in this review included randomized controlled trials (RCTs) (n = 29), quasi-experimental studies (n = 5), single-group pre-test/post-test studies (n = 5), prospective cohort studies (n = 6), and retrospective cohort studies (n = 4). Studies are grouped by type and discussed below, with detailed information in Table 2.

Facility-based Interventions
Facility-based interventions Multi-component interventions that are delivered and/or organized at the facility level. Examples of activities include individual and group counseling, patient-fast tracking, educational classes and materials. These interventions tend to focus on providing comprehensive support and care to ART patients.

Disability grants
Providing monetary grants to people that meet clinical criteria for advanced stages of HIV to provide support until they are well enough to return to work. copies/mL) Statistically significantly lower rates of virologic failure between those that received counseling compared to those that did not 18 months after ART initiation (p = 0.008).
No statistically significant differences in rates of <80% adherence between those that received alarm reminders and those that did not 18 months after ART initiation (p = 0.7).
No statistically significant differences in risk of virologic failure between those that received alarm reminders and those that did not 18  Control: Matched group of participants receiving standard of care (not described) in addition to 6-session education, nutritional support, and visits by "control" Ashas that evaluated adherence but did not assist women overcome adherence barriers. (Continued) Systematic review: ART adherence interventions for ALHIV in LMIC

2007-2009
Uganda HIV-infected adult women that were ART-naïve, pre-partum or postpartum and referred by an affiliated PMTCT program to receive care at a Hospital ART clinic.

RCT
Patients initiated ART and attended 2-and 12-month follow-up appointments with a doctor and certified counsellor. Patients visited with only a nurse and peer counsellor during remaining follow-up appointments at week 2 and months 1,3,6, and 9.
Peer counsellors were clinic patients currently on ART trained in basic counseling who also conducted home visits if participants missed an appointment.
Continuous adherence (Pill count) Cumulative probabilities of virologic success were similar between intervention and control groups (p = 0.733).

Group adherence counseling
Group counseling interventions were described in seven studies, five of which were conducted among adults [51, 52, 54, 56, 57] and two among adolescents [58, 60]. Among adults, statistically significant results were found in only one of the five studies, which were overall of fair quality. A quasi-experimental pilot study in Nigeria found significant differences in mean adherence (Z = -3.581, p<0.001) and three other adherence outcomes between adult women receiving a group motivational interviewing intervention and women that did not [51]; however, this evidence is limited because baseline measures were not presented. An RCT in Zambia found significant improvements in adherence among adults receiving a group counseling intervention compared to individual counseling; however, these differences were no longer detectable once the groups were crossed over, and adherence decreased in both groups [52]. Based on these studies, evidence supporting group counseling as a strategy to improve adherence among adults is currently lacking.
Among the two studies that evaluated group counseling for ALHIV (Figs 2 and 3), one found statistically significant intervention effects [58] and the other did not [60]. A pilot RCT in Thailand delivered group counseling to adolescents (15-24 years) and found significant Systematic review: ART adherence interventions for ALHIV in LMIC differences in the proportions of patients >95% adherent to ART at endline (χ 2 = 14.723, p<0.001) [58]. A second pilot RCT in South Africa evaluated a group counseling intervention delivered to young ALHIV (10-13 years) and their family members and did not find a significant treatment effect (β = 1.527, p = 0.05) [60]. It is difficult to draw conclusions based on two studies with small sample sizes; however, the presence of some significant findings for the effect of group counseling on adolescent adherence shows that further investigation is warranted.

Individual plus group adherence counseling
An RCT in Indonesia used a psychiatrist to deliver both individual and group counseling sessions to adult women and found no statistically significant effects on self-reported adherence or viral load [61]. The validity of these findings are uncertain given the authors' failure to describe the control group or report p-values for outcome analyses, and reporting of point estimates outside of reported confidence intervals.

mHealth interventions
Thirteen studies described interventions that included the use of mobile phones as a platform to improve adherence [63-75]; 12 of these studies were conducted among adults [63-67, [69][70][71][72][73][74][75] and one was conducted among adults and adolescents combined [68]. Interventions included SMS reminder messages sent at regular intervals or triggered by EAMDs, interactive Systematic review: ART adherence interventions for ALHIV in LMIC voice response (IVR) phone calls, and multi-faceted interventions using SMS reminders combined with adherence counseling.

SMS reminders
Four RCTs conducted among adults tested interventions that reminded participants to take their medications by sending SMS messages at regular intervals [63][64][65][66]. A multi-site RCT in Kenya found that receiving weekly SMS that solicited responses from participants decreased rates of non-adherence (RR = 0.81 [0.69, 0.94]) and virologic failure (RR = 0.85 [0.72, 0.99]) among intervention participants compared to a standard-of-care control [63]. Another RCT in Kenya compared each of four study arms-short daily messages, short weekly messages, long daily messages, and long weekly messages-to a control of no SMS reminders and found no statistically significant effects [64]. Additional analyses revealed that weekly delivery of SMS (whether short or long) was associated with improved adherence compared to the control (p = 0.03), but no effect was observed for other combined groups of daily, short, or long reminders [64]. The remaining two studies found no effect on adherence [65,66]. The mixed results of these four studies-which were overall fair quality-provides no clear support for the effectiveness of SMS reminders to improve adherence. Statistically significant results from the study that asked participants to respond to the SMS rather than sending "one-way" messages indicate that further investigation into the effectiveness of this strategy is warranted.

EAMD-triggered SMS reminders
Two good-quality RCTs evaluated interventions that delivered triggered SMS reminders when EAMDs were not opened during scheduled dosing periods [67,68]. An RCT conducted among adults initiating ART in China found statistically significant differences between intervention and control groups in the likelihood of achieving !95% adherence (RR = 1.69 [1.29, 2.21]) and mean adherence (p = 0.003) post-intervention [67]. The study did not find significant differences in virologic outcomes, which may be attributable to the relatively short followup time (6 months) or to high rates of viral suppression in the control group (98%) at baseline. Another RCT conducted with adults and adolescents in South Africa found no significant effects on adherence or virologic failure after 6 months on the intervention [68]. Given the mixed findings of these two studies, more research is needed to better explore the potential of EAMD-triggered SMS reminders.

IVR or phone call reminders
Four studies conducted among adults tested the use of IVR calls or phone calls as reminders to improve adherence [69][70][71][72]; three of these found statistically significant results [69][70][71]. A single-group pre-test/post-test study in India that provided twice-daily IVR calls as well as SMS appointment reminders found significant increases in time elapsed since participants missed a dose (p = 0.015) from baseline to post-intervention [69]. Another single-group pre-test/posttest study in India that examined the effect of weekly IVR calls combined with picture SMS found a significant increase from baseline to post-intervention in the proportion of participants with !95% adherence (85% to 94%, p = 0.016) [70]; however, the study had a substantial (36%) refusal rate. An RCT in Pakistan combined a patient-designed ART dosing schedule with weekly reminder phone calls and found significant differences in proportions of patients reaching optimal adherence (reported as p = 0.000) and viral suppression (p = 0.012) between intervention and control groups [71]. The fourth study examined the effect of IVR calls on adherence and did not find significant intervention effects [72]. Despite significant results from three out of the four studies, the strength of the evidence is limited by nonexperimental study designs [69,70] and methodological issues such as high refusal rates [70] and short intervention and follow-up times [69].

SMS or alarm reminders plus individual adherence counseling
Three studies found mixed results on the effect of SMS or alarm device reminders combined with individual adherence counseling for adults [73][74][75]. An RCT in Nigeria examined the effects of individual adherence counseling and twice-weekly SMS reminders for non-adherent adults and found significant differences in the number of participants who achieved !95% self-reported adherence (χ 2 = 5.211, p = 0.022) and in mean CD4 cell count (Mann-Whitney U-test, U = 2.44, p = 0.007) between intervention and control groups at endline [73]. However, the proportion of participants achieving adequate adherence was still sub-optimal (76.9% intervention, 55.8% control). A four-arm RCT in Kenya compared adherence improvements and rates of virologic failure between participants receiving individual adherence counseling, alarm reminders, or both counseling and reminders and patients receiving standard of care; the study only found statistically significant differences in virologic failure rates (p = 0.008) between participants who received adherence counseling and those who did not regardless of receiving reminders [74]. A third RCT in China allowed participants to self-select into one of three intervention conditions (alarm device, adherence counseling, or alarm device plus counseling) and compared all intervention participants to a control group receiving adherence education; the study found positive results on self-reported adherence (OR = 2.23 [1.05, 4.72]) and did not find any effect on clinical adherence measures [75]. Given the mixed results and methodological quality issues of these studies, better-designed and -implemented studies should be conducted before this strategy's effectiveness can be determined.
Among the six overall fair-quality CBAS intervention studies conducted among adults [76][77][78][79][80][81], five had statistically significant results [76][77][78][79][80]. An RCT in China provided home visits by nurses and peer educators to non-adherent adults and found that greater proportions of patients achieved !90% adherence over the intervention period compared to the control (84% intervention, 53% control, p = 0.009) in adjusted analyses [76]; however, this study was limited by high loss to follow-up in the control group. A quasi-experimental study in Uganda provided weekly home visits by volunteer community members to perform pill counts, deliver ARTs, and assess clinical problems and provide referrals; compared clinic-based patients, participants had significantly higher odds of achieving virologic suppression (OR = 2.47 [1.01, 6.04]) [77]. A prospective observational cohort study compared patients receiving weekly home visits by patient advocates to patients receiving clinic-based care and found that patients receiving home visits were significantly more likely to be retained in care with a suppressed viral load after one year (aRR = 1.15 [1.03, 1.27]) [78]. Two additional studies found positive results [79,80]; but were limited by selection bias [80] and differential attrition [79]. Despite some methodological limitations, current evidence suggests this intervention strategy warrants exploration.
Two retrospective cohort studies conducted among adults and adolescents found statistically significant associations between exposure to CBAS and adherence [82,83]. A study in South Africa examined exposure to Patient Advocates (PA) as part of a CBAS project and observed higher odds of achieving viral suppression among patients who had PAs assigned to them compared to those who did not (aOR = 1.22 [1.14, 1.30] at 6 months; aOR = 2.66 [1.61, 4.4] at 5 years) [82]; however, these findings were limited by incomplete data and no measurement of the exposure or frequency of interactions with PAs. A second study in South Africa also compared adherence rates by exposure to PAs among patients and observed significantly higher rates of adequate adherence (X 2 = 6.131; p = 0.021) among those with PAs compared to those who did not [83]; however, the evidence is weakened by selection bias as study sites were selected based on the completeness of data available. These two observational studies provide initial evidence that assignment to PAs may improve adherence, but methodological problems limit confidence in their results.

Multi-component facility-and community-based program
Two publications described one observational study that evaluated associations between program uptake and treatment outcomes among adults in Kenya [40,41]. Program components included home visits by CHWs, treatment supporters, support groups, clinician pill counts, and pharmacist counseling. One publication reported significantly higher adherence among those who had participated in more than three support group meetings (p<0.05) and those who had four or more unannounced clinician pill counts (p = 0.001) compared to those who did not [40]. The second publication found a positive linear relationship between adherence and the number of unannounced pill counts performed (r = 0.21, p<0.01) [41].

Peer treatment supporters
Two RCTs evaluated peer treatment supporters that provided adherence reminders or DOT to adult patients [84,85]. An RCT in Uganda found a significantly higher proportion of participants receiving adherence reminders from treatment supporters were !95% adherent compared to the control at endline (OR = 4.51 [1.22, 16.62], p = 0.027), but found no significant differences in mean adherence [84]. The second RCT, conducted among adults across sites in eight countries, tested the effect of DOT provided by peer treatment supporters but found no significant effects on adherence or virologic failure among adults on second-line ART [85]. Although both studies had randomized designs and were of good quality, the lack of consistent results and the small number of studies indicate the need for more research to determine the effectiveness of this strategy.

Community-based social network support
A quasi-experimental study in Kenya examined impacts on ART adherence of a communitybased social network support intervention that provided education and social support to groups consisting of one HIV-infected individual and his or her close friends or family members [86]; no significant differences in hair ART concentrations were observed between the intervention and comparison groups. However, it should be noted that there were markedly higher refusal rates among the intervention group than in the comparison group, and that results may have been influenced by contamination between study groups.

Pharmacist counseling
One RCT tested a structured counseling intervention delivered by pharmacists to adult ART patients in Brazil that had no effects on self-reported adherence or viral load [87]. The authors attributed the lack of significant findings to high baseline adherence among study participants.

Depression treatment
An RCT in South Africa randomized HIV-infected adult patients with clinically diagnosed depression to receive either pharmacological treatment for depression or interpersonal psychotherapy and compared changes in patients' adherence to patients without depression receiving standard of care [89]. There were no significant differences between either treatment arm and the control group, or between the two treatment arms. This study is limited by differences in baseline characteristics of individuals in the intervention and control groups as well as by a small sample size (n = 30 control group, 32 intervention group).

Facility-based interventions
Three studies examined the impact of facility-based interventions to increase adult patients' ART adherence through strengthened patient services, support services such as adherence reminders, and changes to staff training and clinic workflow [90,92,93]; two of these studies reported statistically significant effects [90,92]. A single-group, pre-test/post-test study in Uganda tested an enhanced adherence package that provided improved counseling, health education, adherence diaries, mobile reminders, treatment supporters, tracing, and strengthened adherence monitoring [90]. The study found that participants experienced a significant increase in mean adherence (97.4% to 99.1%, p<0.001) and that the proportion of participants with !95% adherence increased over time (7.0% [4.6, 9.4] p = 0.001). Another single-group, pre-test/post-test study in Uganda introduced a new appointment system, provided appointment reminders, encouraged providers to give longer prescriptions to reduce refill frequency, and "fast tracked" stable patients needing ART refills [92]. The study found a significant decrease in the odds having a gap in taking medication over the past 3 days comparing pre-to post-intervention (aOR = 0.69 [0.60, 0.79]). A third, quasi-experimental study that examined increased adherence monitoring and targeted adherence counseling for non-adherent patients did not find significant intervention effects; however, baseline adherence was high (>90%) in both study groups [93]. Although two studies found statistically significant results, their nonexperimental study designs limit the strength of these findings.

Nutrition support
Four studies (two RCTs, one quasi-experimental study, and one retrospective cohort study) evaluated nutrition-support interventions [94][95][96][97]; three found statistically significant effects on adherence [94][95][96]. A quasi-experimental study in Zambia found significantly different estimates of mean adherence at endline between intervention and comparison groups (t = 4.06, p<0.01) [94]. Significant positive results were also found in a retrospective cohort study in Niger that examined associations between exposure to a monthly food ration and mean adherence (p<0.005) and mean CD4 counts (aRR = 43.0 [4.5, 81.5]) [95]. These findings are limited by their observational nature and the fact that no baseline adherence or clinical measures were reported for the exposure groups. The provision of a monthly household food basket was also examined in an RCT in Honduras [96] that found that participants receiving nutritional education plus the food basket had fewer delayed pharmacy refills than those receiving education only (β = -0.196, p<0.01) but did not have any effect on self-reported adherence or missed appointments. The fourth study, an RCT in Haiti, compared a standard ready-to-use supplementary food to a less expensive corn-soy blend on a variety of clinical outcomes including adherence [97]; over the 12-month intervention, adherence did not change significantly in either group nor were there significant differences between the two groups' adherence at any time point (0, 6, and 12 months). Positive effects from the three studies that examined adding nutrition support to ART care provide preliminary evidence for the use of this strategy to improve adherence among adult patients.

Disability grants
One prospective cohort study examined the relationship between adherence and receiving disability grants among adult patients initiating ART in South Africa [98]. The authors compared self-reported adherence between patients continuing to receive a disability grant and those that had received a grant and later lost their eligibility status and found no statistically significant association, likely due to the fact that over 90% of study participants maintained >95% adherence while receiving and after losing the grants.

Task-shifting and decentralization interventions
Four studies tested ART service delivery interventions for adult patients [99][100][101][102]; three of these evaluated task-shifting of services from physicians to lay health workers, nurses, or peer counsellors [99][100][101], and one evaluated providing decentralized services at semi-mobile clinics [102].

Task shifting
Three RCTs evaluated task-shifting of ART care and found equivalent or improved adherence outcomes for adult patients who received ART services from lay health workers, nurses, or peer counsellors compared to those who remained in standard care delivered by a physician or clinical officer [99][100][101]. A study in South Africa found comparable rates of viral suppression and significantly higher mean CD4 counts at follow-up for participants who visited trained nurses for ART re-prescription compared to doctors (β = 24.2 [7.2, 41.3], p = 0.007) [99]. The other two studies, one which shifted services from doctors and certified counsellors to nurses and peer counsellors, and the other which provided care by trained lay health workers, demonstrated that services provided by lower cadre or lay health providers were not inferior to standard of care services [100,101]. Two of the interventions required patients to be stable on ART for a defined period before they were eligible for task-shifted services [99,101], which may limit the utility of this intervention for individuals initiating ART or experiencing clinical or adherence issues. Although limited in number, the three task-shifting studies provide promising indications that stable patients who are down-referred for ART care experience equivalent, if not improved, adherence compared to standard care.

Decentralization
One retrospective cohort study in Kenya examined the association between receiving care at a decentralized, semi-mobile clinic or a district hospital and adherence and CD4 cell counts [102]. This study found no statistically significant associations between where patients received care and their mean CD4 count or pill-count adherence; high proportions of patients reported taking all of their medication (81% of hospital-based patients, 86% of semi-mobile clinic patients).

Limitations of the reviewed studies
The quality of the studies included in this review varied; fewer than one-third of all studies achieved a "good" quality rating, and nearly all of these were RCTs. Our assessment of a study's quality was often limited due to a failure to report critical information such as sample size or power calculations or participant inclusion criteria, or to adequately describe analyses or measures. Moreover, a substantial number of studies were affected by large, and often differential, attrition of study participants. Some studies, particularly several that did not find statistically significant intervention effects, were presented as pilot studies and were inadequately powered to detect modest effect sizes. A lack of methodologically rigorous, adequately powered studies, particularly among adolescents, makes it difficult to draw conclusions with regard to their potential for future implementation. More rigorous research in this field is critical, as is replication of studies with positive findings in other settings. Furthermore, many of the studies described in this review were multifaceted, with some delivering multiple intervention components and others providing adherence support as a part of a broader package of services; this makes it impossible to discern the relative effect of each intervention component or identify which aspects are most impactful on adherence.
Another limitation of these studies, and of adherence research as a whole, lies in the challenge of accurately measuring medication adherence and in the variety of methodologies utilized. Beyond issues of validity and precision of each measure used, it is difficult to compare the effectiveness of studies reporting different measures or different definitions of adequate adherence.

Recommendations
Interventions that involved task shifting and community-based adherence support had the most promising evidence for adult populations, and should be tested among ALHIV. Additionally, research should examine the acceptability and cost-effectiveness of adapting community-based adherence support interventions for ALHIV.
Interventions that used mHealth platforms were numerous, but largely focused on simple adherence reminders; new strategies for using mHealth platforms to improve adherence should be developed and evaluated with a special focus on soliciting participant engagement as well as targeting the specific barriers to adherence experienced by ALHIV.
Nutrition support found favorable results among adults, but future implementation may be hindered by high cost and an increasingly difficult funding environment. Adaptation and testing of nutrition support interventions for ALHIV may only be warranted in settings that are amenable to long-term support for this strategy.
The two studies that evaluated the effect of group adherence counseling interventions for adolescents provided preliminary evidence as to its utility. Further research should be conducted on this topic, particularly focusing on providing targeted counseling for ALHIV with suboptimal adherence.