Social interactions and support have long-term physiological, psychological, and behavioral consequences impacting health outcomes. The importance of social support in improving health outcomes has le

©INTERNATIONAL CENTRE FOR DIARRHOEALDISEASE RESEARCH, BANGLADESH J HEALTH POPUL NUTR 2013 Jun;31(2):150-170 ISSN 1606-0997 | $ 5.00+0.20 Correspondence and reprint requests:

Professor Karl Peltzer Human Sciences Research Council Private Bag X41 Pretoria 0001 South Africa Email: [email protected] INTRODUCTION The clinical efficacy of antiretroviral therapy (ART) in suppressing the HIV virus and improving sur- vival rates for those living with HIV has been well- documented (1-3). However, successful antiretrovi- ral therapy is dependent on sustaining high levels of adherence (correct dosage, taken on time, and in the correct way—either with or without food). The minimum level of adherence required for antiretro- viral drugs to work effectively is 95% (4). Although more potent antiretroviral regimens can allow for effective viral suppression at moderate levels of adherence, no or partial adherence can lead to the development of drug-resistant strains of the virus (5-7). Adherence to ART is influenced by factors as- sociated with the patient, the disease, the therapy, and the relationship of the patient with healthcare provider (8-10). Patient-related factors include so- cioeconomic status (SES) (8,10).

A review of studies since 2005 on SES and adher- ence to ART primarily in high-income countries, did not provide conclusive support for a clear asso- ciation between SES and adherence (8). However, it is not clear what effect socioeconomic factors have on adherence to ART in low- and middle-income REVIEW ARTICLE Socioeconomic Factors in Adherence to HIV Therapy in Low- and Middle-income Countries Karl Peltzer 1,2,3 , Supa Pengpid 2,3 1HIV/AIDS/SIT/and TB (HAST), Human Sciences Research Council, Pretoria,\ South Africa; 2 Department of Psychology, University of Limpopo, Turfloop, South Africa; 3ASEAN Institute for Health Development, Madidol University, Salaya, Phutthamonthon, Nakhonpathom, Thailand 73170 ABSTRACT It is not clear what effect socioeconomic factors have on adherence to antiretroviral therapy (ART) among patients in low- and middle-income countries. We performed a systematic review of the association of socioeconomic status (SES) with adherence to treatment of patients with HIV/AIDS in low- and middle- income countries. We searched electronic databases to identify studies concerning SES and HIV/AIDS and collected data on the association between various determinants of SES (income, education, occupation) and adherence to ART in low- and middle-income countries. From 252 potentially-relevant articles ini- tially identified, 62 original studies were reviewed in detail, which contained data evaluating the associa- tion between SES and adherence to treatment of patients with HIV/AIDS. Income, level of education, and employment/occupational status were significantly and positively associated with the level of adherence in 15 studies (41.7%), 10 studies (20.4%), and 3 studies (11.1%) respectively out of 36, 49, and 27 studies reviewed. One study for income, four studies for education, and two studies for employment found a nega- tive and significant association with adherence to ART. However, the aforementioned SES determinants were not found to be significantly associated with adherence in relation to 20 income-related (55.6%), 35 education-related (71.4%), 23 employment/occupational status-related (81.5%), and 2 SES-related (100%) studies. The systematic review of the available evidence does not provide conclusive support for the exis- tence of a clear association between SES and adherence to ART among adult patients infected with HIV/ AIDS in low- and middle-income countries. There seems to be a positive trend among components of SES (income, education, employment status) and adherence to antiretroviral therapy in many of the reviewed studies.

Keywords: Antiretroviral therapy, highly active; Education; Employment; Income; Occupations; Social class Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy Volume 31 | Number 2 | June 2013 151 countries. A possible association between SES and adherence to ART among HIV patients may have an impact on the success of their treatment (8,10). MATERIALS AND METHODS Literature search We performed a systematic search of the litera- ture to identify reviews and original studies that reported data on the impact of SES on adherence to ART. The relevant studies were identified by the use of electronic databases, such as MEDLINE, EMBASE, SCI Web or Science, NLM Gateway, and Google Scholar. The last search was conducted in November 2011. In addition, relevant articles from the list of references of the initially-retrieved papers were identified. Studies conducted only in low- and middle-income countries were included, according to World Bank classifications (11).

Five different search strategies using the follow - ing key words were employed: (i) Socioeconomic status AND (HIV OR AIDS) AND (compliance OR adherence), (ii) (Compliance OR adherence) AND (HIV OR AIDS) AND determinants, (iii) (AIDS OR HIV) AND (compliance OR adherence) AND edu- cation AND/OR income AND/OR occupation, (iv) (AIDS OR HIV) AND (compliance OR adherence) AND determinants, and (v) (AIDS OR HIV) AND (compliance OR adherence).

Defining socioeconomic status (SES) is difficult because a single, consistent unit of measurement was not used in the studies reviewed. Further, a debate exists in the public-health arena on the appropriate components of socioeconomic sta- tus and methods of measurement (12). Krieger et al. (13) have argued that it is important to dis- tinguish two different components of socioeco- nomic position (actual resources and prestige or rank-related characteristics), and they preferred the use of the term ‘socioeconomic position’ in- stead of ‘socioeconomic status’. In addition, they argued that it is important to collect data at the individual, household and neighbourhood level (12,13). Additional points emphasized included that data on individuals supported from ‘annual family income’ should be collected, measure- ments should incorporate the recognition that socioeconomic position can change over a life- time, and measures of socioeconomic position may perform differentially based on racial/eth- nic group and gender background (12,13). Most of the reviewed articles did not attend to these complexities, rather used one to three mea- sures of SES, most often simplistic measures of income, education, and occupation or employ- ment status. The reviewed articles were analyzed with the understanding that the complexities present in SES highlighted by Krieger et al. (13) should ideally be incorporated in future studies designed to tease out the relationship between SES and adherence to ART in low- and middle- income populations. Meanwhile, the term SES is used in this article rather than socioeconomic position, simply because this is how these mea- sures were discussed by the authors in the pa- pers reviewed (12). SES reflects different aspects of social stratification, and the traditional indi- cators at the individual level have been income, education, and occupation (14,15). There is no single-best indicator of SES suitable for all study objectives and applicable at all time-points in all settings. Each indicator measures different, often related aspects of socioeconomic stratifi- cation and may be more or less relevant to dif- ferent health outcomes and at different stages in the course of life (15). Galobardes et al. (16) described the theoretical basis of the following three indicators used for measuring SES:

(a) Education attempts to capture the knowledge- related assets of a person. As formal education is normally completed in young adulthood and is strongly determined by parental char- acteristics, it can be conceptualized within a course of life framework as an indicator that, in part, measures socioeconomic position (SEP) in early life (16).

(b) Income is the indicator of SEP that most di- rectly measures the material resources com- ponent (16).

(c) Occupation represents Weber’s notion of SEP as a reflection of a person’s place in soci- ety relating to their social standing, income, and intellect (16). Selection of studies The inclusion and exclusion criteria used for the reviewed studies were set before the literature search. Studies included in our study concerned only individual HIV-infected adult patients and their adherence to antiretroviral therapy. Re- views and editorials were not included in our systematic review. Studies that focused on HIV- infected illicit and/or licit drug-users and/or those with severe mental illness were excluded since such persons may need more creative ap- proaches than other patients to ART adherence that differentiates them from the general popu- Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy JHPN 152 lation (8,17-19) . Two authors of the present ar- ticle evaluated the eligibility studies obtained from the literature search using a predefined protocol. The two authors worked independently to scan all ab - stracts and obtained full-text articles. In cases of dis- crepancy, agreement was reached by consensus.

Data extraction Two authors of the present article independently extracted and compiled the data. For each identified study that met the selection criteria, details were extracted on study design, characteristics of study population, data relevant to SES, the measure of adherence, the overall adherence, and findings re- garding the association between determinants of SES and adherence on to an Excel spreadsheet. In this review, three parameters as major factors con- tributing to SES were assessed, namely income, ed- ucation, occupation/employment status and their association with adherence to ART.

The following diagram presents the various steps in the process of selecting studies. RESULTS AND DISCUSSION The literature search identified 252 potentially- relevant studies, from which we further reviewed 62 studies with original data. In Annexure A-F, the characteristics of 62 studies that were in- cluded in the systematic review are presented by region and country. The year of publication of the studies ranged from 2002 to 2011. There was considerable variability across the studies in setting and patient population, largely because these were conducted in different low-resource settings, with different cultures, incomes, and education levels (Table 1).

Regarding the study design, 44 cross-sectional (21,24,26,28-31,33-37,41,42,47-49,53,55,56,58-72, 74-76,78-82), 19 longitudinal (22,25,27,32,38- 40, 43-46,50-52,54,57,77), and two case-control (23,73) studies were included in the review. The average number of patients was 400 per study in the total of 62 studies (ranging from 53 to 2,381, depending on the study setting).

252 Potential relevant articles identi ed and screened for retrieval Figure.

Flow-diagram of reviewed studies 105 potentially appropriate studies regarding antiretroviral treatment adherence were further reviewed 147 studies were e xcluded because these were not relevant to this study 100 studies included data relevant tothe association between SES and adherence to antiretroviral treatment 5 studies were e xcluded because these were reviews 73 studies remained for further analysis 27 studies were excluded because of the following:

• Health literacy (exclusively) and its in uence on adherence (5) • HIV knowledge, ARV knowledge (3) • SES only descriptive information (17) • SES not disaggregated in analysis (e.g. vulnerability, including SES and other variables) (3) 62 original studies remained for further analysis and were included in this review 11 studies were excluded because of the following: • These referred to illicit and licit drug-users infected with HIV (6) • These referred to persons with serious mental illness infected with HIV (2) • These referred to HIV-TB co-infected persons • Inmates (3) Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy Volume 31 | Number 2 | June 2013 153 Table 2. Summary of studies on the association between the main components of socioeconomic status and adherence to antiretroviral therapy SES component Number of studies N Positive association N (%) Negative association N (%) No association N (%) Education 4910 (20.4) 4 (8.2)35 (71.4) Income 3615 (41.7) 1 (2.8)20 (55.6) Occupation/employment 273 (11.1) 2 (7.4)22 (81.5) SES 2002 (100) Studies varied in the measurement of adherence (pills per dose, doses per day, days of treatment per week, time schedule for pill-refill, etc.) and used different cutoff points of adherence (from 80% to 100% of dosage) to dichotomize the patients be- tween adherence and non-adherence to ART. Two studies focused directly on the association between SES or its main determinants analyzed as a group and adherence (40,78). The available reported data regarding the method, with which adherence to an- tiretroviral treatment was measured, and the data on overall adherence are presented in Annexure A-F. In 50 out of 62 studies included in the review, self-report by the patients was the main measure of adherence to treatment (21,22,24,26,27,29-32,34- 37,39,41,42,44-49,51,53,56,58-69,70-82); six stud- ies used pill counts, MEMS, pharmacy refills as the main measures (23,40,43,54,55,57), and in six Table 1. Education and income (country indicators) in study countries Country Education Income Adult literacy (%) Primary school enrollment rate: Male/Female Gross national income per capita (PPP int. $) Living on <1$ (PPP int. $) a day (%) Botswana 8386/88 12,840 - Brazil 9095/93 10,200 5.2 Burkina Faso 2967/59 1,17056.5 Cameroon 7697/86 2,19032.1 China 94-6,890 15.9 Columbia 9393/80 8,60016.0 Costa Rica 96-10,930 2.0 Cuba 10099/99 -- Dominican Republic 8892/82 8,110 4.4 Ethiopia 3685/80 93039.0 India 6391/88 3,25041.6 Ivory Coast 5562/52 1,64023.3 Jamaica 8682/79 7,230<2.0 Kenya 8782/83 1,57019.7 Mali 2679/66 1,19051.4 Nigeria 6064/58 2,07064.4 Papua New Guinea 60-2,260 - Rwanda 7095/97 1,06076.6 Senegal 4272/74 1,81033.5 South Africa 9587/88 10,050 26.2 The Gambia 4567/71 1,33034.3 Thailand 9491/89 7,640<2.0 Uganda 7596/99 1,19051.5 United Republic of Tanzania 7396/97 1,35088.5 Zambia 7196/92 1,28064.3 Source: World health statistics 2011 (20) Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy JHPN 154 studies both self-report and objective adherence measures (25,28,33,38,50,52) were used.

The main parameters affecting SES (income, educa- tion, occupation) were only examined as a group comprising SES in two studies but, in 61 studies, these were rather regarded as socioeconomic char- acteristics. Therefore, many studies lacked data concerning some of the parameters. There were insufficient data regarding income in 26 stud- ies (22,28,29,31,33,37,38,41,47,48,50,51,53,54, 56,60,68-70,72,74,75,80-82) and educational level in 14 (26,28,30,37,39-41,46,59,61,62,65,68) of the 62 reviewed studies (Some of the studies had data on income but not on education, and others had the reverse). Employment and/or oc- cupational status was assessed in 28 studies (22- 24,28,29,31,34-37,39-42,44,45,53,54,58,59,61,67- 69,70,77,78,81,82). However, no data were given on occupational status or working position in 18 of those 28 studies.

The main findings regarding the analysis of the as- sociation of SES or the various components of SES and adherence were as follows: income, level of education, and employment/occupational sta- tus were significantly and positively associated with the level of adherence in 15 studies (41.7%) (21,2 4,26,32,39,43,46,49,62,63,65-67,76,78), 10 stud ies (20.4%) (33,35,53,66,69,71-73,75,77), and three studies (11.1%) (28,29,77) respectively out of 36, 49, and 27 studies reviewed. Most significant findings refer to a positive associa - tion between levels of SES components and lev- els of adherence to antiretroviral treatment, al- though one for income (59), four for education (21,31,43,63) and two for employment (59,77) of the reviewed studies suggest an inverse asso - ciation with adherence. However, the aforemen - tioned SES determinants were not found to be sig - nificantly associated with adherence in relation to 20 income-related studies (71,73,23,24,25,30,34- 36,42,43,45,57,61,77), 35 education-related stud - ies (22-25,27,29,32,34,36,38,42,44,45,47-52, 60,64,67,70,74,76,78-81,82), 22 employment/ occupational status-related studies (22-24,34- 36,41,42,44,45,49,53,54,58,67-70,78,79,81,82) and two SES-related studies (40,78) (Table 2). Limitations This systematic review has several limitations. First, it was not possible to make a synthesis of the data, using the principles of meta-analysis due to the fact that there was considerable heterogeneity among the reviewed studies. Adherence was measured by different methods in each of the studies and the cutoff percentage of adherence to treatment be- tween ‘adherent’ and ‘non-adherent’ varied among the studies. Another limitation was that the ma- jority of the studies examined the used unreliable measures of adherence (self-report, in particular) as the adherence outcome measure. In addition, SES was not focused upon as a homogenous group of specific factors in most of the reviewed studies but was rather dispersed among its components, which were regarded as socioeconomic informa- tion. Therefore, partial data had to be collected re- garding the association of such SES components, and adherence to antiretroviral therapy, where and if such an association was assessed. Occupation was mainly assessed in terms of employment status because often no data were given on status of oc- cupation or working position of the patients (8). Conclusions The systematic review of the available evidence found a positive trend among components of SES (income, education, occupation/employment) and adherence to antiretroviral therapy in many of the reviewed studies. However, we found inconclusive support for a clear association between SES and ad- herence among patients infected with HIV/AIDS in low- and middle-income countries. The association between SES and adherence may differ depend- ing on the cultural/economic/geographic context of the countries studied, and results emphasize a site-specific approach to adherence studies and programmes. Future studies should measure socio- economic factors more accurately and, thus, may further explain the different impacts of SES to ART adherence. In the absence of a gold standard for measure of adherence, future studies should assess many outcomes. REFERENCES 1.

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82. Williams M, Clarke T, Williams P, Barton EN. The mean levels of adherence and factors contributing to non-adherence in patients on highly active antiretro- viral therapy. West Indian Med J 2007;56:270-4. Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy JHPN 158 Annexure A. Impact of socioeconomic factors on HAART adherence among adults: study c\ haracteristics (Africa 1) Country of study, year of publication, first author (Refer- ence number) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence Botswana 1 [2003] Weiser (21) Cross- sectional study 109 patients, 40 patients combina- tion therapy with 2 nucleoside reverse transcriptase inhibi- tors (NRTIs) and 1 protease inhibitor, 2 NRTIs and 1 non- NRTI, or 2 protease inhibitors Self-reported adherence over the previous day, week, month, and year; 54% of patients were adherent (≥95% by self-report while 56% were adher- ent by providers’ assessment Secondary school or more: 87%; From those who missed treatment, 48% said because of financesCost is a barrier to treatment: AOR=0.15, 0.06–0.35; Incomplete secondary education:

AOR=3.87, 1.21–12.40 Botswana 2 [2010] Do (22) Cross- sectional prospective survey; Out- patient adult infectious disease clinic, Gaborone300 adult patients CBV/NVP: 66.0%; CBV/EFV: 25.7% Self-reported, institutional adherence, and a culturally-modified Morisky scale; The overall ART adherence rate was 81.3% based on 4-day and 1-month patient recall and on clinic attendance for ARV medication refills during the previous 3 months Unemployed: 44.3%; Sec- ondary education: 55.7% Level of education:

NS; Employment status: NS Botswana 3 [2011] Gust (23) Case-control study; 8 public health urban clinics 252 adherent patients; 127 non- adherent patients Pharmacy refill visits; Criterion of attending ≥80% of visits within 6-month period Secondary education:

54.6%; Employed: 63.7%; Income per month (Pula:

0-900): 48.8%Education: NS; Em- ployment status: NS; Income: NS Cameroon 1 [2009] Boyer (24) Cross- sectional study; 6 pub- lic hospitals 532 patients Self-reported dosie-taking during the prior 4 days and dosing time sched- ule in the past 4 weeks; the 53.9% to 100% adherent in dose-taking in the past 4 days and dosing time schedule in the past 4 weeks 20% financial difficulty in purchasing their ARVs; Completed primary edu- cation: 55.6%; Monthly household income (me- dian): US$ 128; Having economic activity: 70.8% Difficulty in buying ARV: OR=0.24 (0.15- 0.4); Education: NS; Household income:

NS; Having economic activity: NS Contd. Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy Volume 31 | Number 2 | June 2013 159 Annexure A—Contd.

Country of study, year of publication, first author (Refer- ence number) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence Cameroon 2 [2009] Rougemont (25) Longitudinal study; Central Hospital, Yaoundé312 patients at the start of ART; Triple- drugs regimens con- sisting of two NRTIs and one non-NRTI Self-reported adherence in the past month; 78% claimed not to have missed a single dose; Pharmacy- records review; 64% pharmacy-ap- pointed dates adherence (renewal of prescription within 2 weeks after the scheduled date) Monthly income of less than US$ 50: 46%; Sec- ondary or more educa- tion: 65% Monthly income: NS; Education: NS Cameroon 3 [2011] Boyer (26) Cross- sectional study; 6 hospitals 2,381 patients Self-reported doses taken and compli- ance with the dosing schedule in the past 4 days; 56.6% good adherence Financial difficulty in purchasing ARVs in pre- vious 3 monthsNon-adherence:

Patients with financial difficulties Cameroon 4 [2011] Roux (27) Prospective cohort study401 patients Self-reported adherence in the past 4 days; 66% adherent (100% of doses in the past 4 days) ≥secondary education: 51%; Subjective social level scale: Median=2 Education: NS; Social level scale: NS Ethiopia 1 [2009] Beyene (28) Cross- sectional study 422 patients Self-reported adherence assessment of 15 days; 93.1% (≥95%); Unannounced pill count method (n=90): 88.1% adherent (≥95%) Unemployed: 59% Unemployment:

AOR=0.01, 0.00-0.29 Ethiopia 2 [2010] Giday (29) Cross- sectional study 510 AIDS patients seen over one month Self-report: 88.2% of them had ≥95% and 97.1% of them had ≥80% an- tiretroviral adherence rate over one month period Occupation: 39.6% no job; No education: 13.5% Having a job; Educa- tion: NS Ethiopia 3 [2010] Tiyou (30) Cross- sectional study 319 adults; HAART regimen of Stavu- dine (d4T), Lamivu- dine (3TC) and Nivi- rapine (NVP):71.8% Self-reported adherence (not missing a single dose) based on the combined indicator of the dose, time and food in the past week was 72.4% Median monthly income of the participants and their family: 300.00 and 350.00 Ethiopian Birr Average family income: NS 95% Confidence intervals; AOR=Adjusted odds ratio; NS=Not significant; OR=Odds ratio; RH=Ris\ k ratio Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy JHPN 160 Annexure B. Impact of socioeconomic factors on HAART adherence among adults: study \ characteristics (Africa 2) Country of study, year of publica- tion, first author (Reference num- ber) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence Ivory Coast [2007] Eholié (31) Cross- sectional study; 3 urban HIV outpatient clinics 308 patients; Mean time on HAART: 22 months Self-report of pill intake during the previ- ous 7 days; The median self-reported adherence rate was 78%; 76% of patients considered incompletely adherent (adher- ence rate <90%) Secondary school or higher: 73% Non-adherence; School level; ≥second- ary: AOR=1.88, 1.06 3.35 Kenya [2010] Unge (32) Prospec- tive open cohort study; African Medi- cal Research Foundation (AMREF) Clinic in the Kibera slum800 patients; First- line ART-regimens:

Stavudine, Lamivu- dine, and Nevi- rapine/Efavirez; Second-line regi- mens, including Zidovudine, Aba- cavir, Didanosine, Ritonavir-boosted Lopinavir (Kaletra), and Tenofovir Self-reported adherence in past 4 days; More than one-third of patients were non-adherent (<95%) when all three aspects of adherence--dosing, timing, and special instructions--were taken into account Up to primary school:

60%; >5000 KSH in- come/month: 59.5% Low adherence index:

Living below poverty limit: AOR=3.28, 1.27- 8.48; Low education:

NS Nigeria 1 [2005] Iliyasu (33) Cross- sectional study; Aminu Kano Teach- ing Hospital, Kano 263 AIDS patients Patient’s reported consumption of antiretroviral drugs was compared with the physician’s prescription in the 7-day period preceding the interview; Only 142 (54.0%) of the 263 respondents took at least 80% of the antiretroviral drugs prescribed. Sixty-one (23.2%) did not miss any dose of the drug Tertiary education:

36.1%; Secondary education: 34.2% Formal education:

OR=3.97; (1.75–9.24) (univariate analysis only) Contd. Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy Volume 31 | Number 2 | June 2013 161 Annexure B—Contd.

Country of study, year of publication, first author (Reference number) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence Nigeria 2 [2008] Shaahu (34) Cross- sectional study 428 patients Self-reported adherence rate was 268 (62.6%), measured as consistent use from onset of study period Unskilled occupation:

70.6%; Post-secondary education: 41.1%; Monthly income ≥5,000 Naira: 40.9%Occupation: NS; Edu- cation: NS; Monthly income: NS Nigeria 3 [2009] Uzochukwu [35] Cross- sectional study 174 patients on ART for at least 12 months Self-reported missing of medication in the past month; 75% not adhering fully to their drug regimen Occupation: Busi- ness/trading 39.6%, civil servant 18.4%, Unemployed: 11.5%; Head of household’s income/month <5000:

48.3%; Years of formal education:Median=4.9 yearsNon-adherence; Formal education; Coefficient=-0.26 (p=0.007); Employ- ment status: NS; Household income:

NS Nigeria 4 [2010] Adewuya (36) Cross- sectional study 182 persons with HIV infection Self-reported Morisky Medication Adher- ence Questionnaire; 26.9% low adherence Secondary-school educa- tion: 50.0%; Low SES (occupational status and income): 34.1%Educational level: NS; SES: NS Nigeria 5 [2010] Salami (37) Cross- sectional study; Ilorin 253 adult patients Self-reported past 30 days; 70.8% adher- ent (≥95%) Employed: 95.7% Employed: Spearman rho=0.59 Nigeria 6 [2010] Ukwe (38) Prospective study 299 patients; HAART type: D4T + 3TC + NVP 219 (73.2%) Self-reported adherence in past 7 days; 86.1% average adherence (≥95%) over 3-month assessment; Use of an adherence aid (pill box) was correlated with adher- ence Secondary education:

45.5% Education: NS 95% Confidence intervals; AOR=Adjusted odds ratio; NS=Not significant; OR=Odds ratio; RH=Ris\ k ratio Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy JHPN 162 Annexure C. Impact of socioeconomic factors on HAART adherence among adults: study c\ haracteristics (Africa 3) Country of study, year of publica- tion, first author (Reference num- ber) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence Senegal [2003] Lanièce (39) Prospective cohort study (2 years)158 adults Self-reported adherence in the past month; 69% optimal (100%) adherence; 91% mean overall adherence Median monthly income:15,000 FCFA (about US$20) (50.6%); Not in paid employ- ment: 41%Free of charge ARVs during 17 months of the study South Africa 1 [2003] Orrell (40) Prospective cohort study; Public sector hospital, Cape Town289 patients Clinic-based pill counts and pharmacy refill data over 48 weeks; The median adherence of the cohort up to 48 weeks was 93.5% Low socioeconomic sta- tus; (income, education, employment): 42% Socioeconomic status:

NS South Africa 2 [2004] Nachega [41] Cross- sectional study; Chris Hani Ba- ragwanath Hospital, Soweto 66 patients; Median duration of ART use for 18 months Self reported adherence; Adherence was >95% for 58 patients (88%) for previous month Employed: 59.9%; SES (employment, tap-water, electricity, overcrowding; Score 0-4): Mean 3.2Employment status:

NS SES: NS South Africa 3 [2008] Malangu (42) Cross- sectional study 180 patients; Mean age of 36.7±8.1 years Self-reported mean number of doses missed during the last seven days prior to the interview was 2.7±3.9; The mean adherence level was 92.3% High school level of edu- cation: 73.9%; Unem- ployed: 86.7%; Received disability grants: 34.4% Education: NS; Em- ployment status: NS; Receiving a disability grant: NS Contd. Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy Volume 31 | Number 2 | June 2013 163 Annexure C—Contd.

Country of study, year of publica- tion, first author (Reference num- ber) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence South Africa 4 [2010] Maqutu (43) Prospective study 688 patients Pharmacy-records (pill counts); During the first month of therapy, 79% of the patients were adherent (≥95%) to HAART Secondary-school or higher level of educa- tion: 68%; Classified as a source of their house- hold’s income: 28%; Owned cell phones:

42%; No schooling: 12%Cellphone ownership:

AOR=1.26, 1.06-1.50; Urban treatment site:

AOR=4.35, 2.26–8.37; No schooling:

AOR=5.04, 1.84-13.82; Income: NS South Africa 5 [2010] Peltzer (44) Prospective cohort study (6 months); 3 hospitals, KwaZulu- Natal735 patients Two self-reported adherence measures; 30-day VAS at ≥95% adherent 82.9%; Self-reported 4-day recall dose adherence 84.5% Grade 8 or higher for- mal education: 61.9%; Formal salary as main source of household in- come: 31.7%; Disability grant: 52.5%; Unem- ployed: 59.6%Education: NS; Employment status:

NS; Disability grant:

NS; Urban residence:

AOR=2.78, 1.60-4.83 South Africa 6 [2011] Peltzer (45) Prospective cohort study (20 months)735 patients; HIV medica- tions for 76.3% patients included Lamivudine (3TC), Stavudine (d4T) + Efavirenz and for 23.7% Lamivudine (3TC), Stavudine (d4T) + Nevirapine Self-reported adherence measure; At 12 and 20 months using the VAS: 89.6% and 91.6% adherent at ≥95% Grade 8 or higher for- mal education: 61.9%; Formal salary as main source of household in- come: 31.7%; Disability grant: 52.5%; Unem- ployed: 59.6%Income: NS; Educa- tion: NS; Employment status: NS; Urban residence: AOR=3.71, 1.56-8.83 95% Confidence intervals; AOR=Adjusted odds ratio; NS=Not significant; OR=Odds ratio; RH=Ris\ k ratio Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy JHPN 164 Annexure D. Impact of socioeconomic factors on HAART adherence among adults: study c\ haracteristics (Africa 4) Country of study, year of publication, first author (Refer- ence number) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence Tanzania 1 [2007] Ramadhani (46) Cross- sectional cohort study 150 patients on ART for at least 6 months Self-reported assessment on incomplete treatment adherence; 84% reported not missing any doses of ART from the start of treatment Weekly ART expenditure per patient: Median USD (range) 18.1 (0–104.4); Duration of self-funded treatment, proportion of treatment duration: 0.12Non-adherence:

Paying for treatment AOR=23.5, 1.2-444.4); Weekly ART expendi- ture: NS Tanzania 2 [2010] Watt (47) Cross- sectional study 340 patients Self-report; 94.1% reporting at least 95% adherence on both four-day and one- month self-report measures Completed primary edu- cation only: 60.9% Education: NS The Gambia [2010] Hegazi (48) Cross- sectional study 147 patients Self-reported adherence; 31% reported missing 1-3 doses in the past month No formal education:

38%Illiteracy: NS Uganda 1 [2005] Byakika-Tusiime (49) Cross- sectional study 304 patients pur- chasing ART Self-reported number of missed doses over the last three days; 44% reported having missed at least one dose of the ARVs in the previous three-month period Post-secondary educa- tion: 63.2%; Monthly income: <500,000 USh (US$ 250): 87.8% Non-adherence:

Monthly, US$ 50:

AOR=2.77, 1.64-4.67 Education: NS Employment: NS Uganda 2 [2008] Abaasa (50) R etrospective cohort study; TASO clinic, Kampala 897 patients Self-report and pill count methods; 21.9% patients had a mean adherence of 95% or less No education: 17.5% Education: NS Uganda 3 [2009] Bajunirwe (51) Prospective cohort study; Kitagata Hos- pital175 patients 3-day self-report to measure adherence; Patients were considered non-adherent if they missed at least 1 antiretroviral pill and 100% adherent if they had not; At baseline, 149 (85%) reported 100% adherence Primary education:

53.1% Non-adherence; Education: NS Uganda 4 [2009] Byakika-Tusiime (52) Longitudinal study 177 patients; 75 patients newly- initiating ART and 102 on stable ART Unannounced pill counts; 3-day self- report and a 30-day visual analogue scale; Mean adherence was over 94% Education >primary:

49.4%; Median monthly income: US$90 Education: NS; In- come: NS Contd. Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy Volume 31 | Number 2 | June 2013 165 Annexure D—Contd. Country of study, year of publication, first author (Refer- ence number) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence Uganda 5 [2009] Nakimuli-Mpun- gu (53) Cross- sectional study 120 adult patients Self-reported missed doses; 17.2% non- adherence (<90%) to HAART in the previous month Secondary education:

32.8%; Employed: 65.6% No education:

OR=0.32, 0.12-0.85; Employment status: NS Uganda 6 [2010] Kunutsor (54) Prospective study over a 28-week period; district hospital392 adult patients; Majority: first-line fixed-dose com- bination regi- men: Zidovudine, Lamivudine, and Nevirapine or Stavudine, Lamivu- dine, and Nevirapine Clinic-based pill count in the past 4 weeks; 98.8% mean medication adher- ence: 93.1% (≥95%) optimal medica- tion adherence Primary education or less: 73%; Unemployed:

55% Education: NS; Em- ployment status: NS Zambia 1 [2008] Carlucci (55) Cross-sectional survey, chart review; Macha Mission Hos- pital424 patients Pill counts; 83.7% had optimal (≥95%) adherence at the first month >Primary education:

40%Education: NS Zambia 2 [2009] Birbeck (56) Retrospective chart review255 patients Self-reported assessment; 59.2% good adherence (attended all scheduled ART clinic visits with no lapse in drug collec- tion and no documentation indicating adherence problems) Primary or less educa- tion: 54.9% Education: NS Zambia 3 [2011] Birbeck (57) Prospective cohort study496 adults Pharmacy-records; Almost 60% had good adherence (no documented lapses in drug acquisition as per pharmacy- records, and no patient or healthcare worker reports of adherence problems) Wealth in household goods; Median=US$ 1,078 (IQR=62-1,523) Food insecurity: 44.4%; Education (mean years): 7.2 Poor adherence; Wealth: NS; Food insecurity: NS; Educa- tion: NS Contd. Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy JHPN 166 Annexure D—Contd. Country of study, year of publication, first author (Refer- ence number) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence Burkina Faso and Mali [2007] Aboubacrine (58) Cross- sectional study; Bamako (n=110) and Ouagadougou (n=160) 270 patients Self-reported number of doses missed yesterday, the day before yesterday, and over the previous week; 58.5% of the patients reported having a complete ART adherence (‘always’ taking their- medication) High school education:

51.5%; Had no revenue or earned

54.6% Paid job: OR=0.67, 0.48-0.93; Own home:

OR=1.48, 1.05-2.11 OR=Odds ratio; AOR=Adjusted odds ratio; 95% Confidence intervals; NS=Not significant; RH=Risk Ratio Annexure E. Impact of socioeconomic factors on HAART adherence among adults: study \ characteristics (Asia 1) Country of study, year of publication, first author (Refer- ence number) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence China [2008] Wang (60) Cross- sectional study; 7 free treatment sites 380 patients; 3-drug regimen Adherence measured by CPCRA self-re- port: 79% taking 100%, (17%); 80-99%, and 4% (0-79%) in the past 7 days Less than high school education: 84% Urban/rural: NS; Level of education: NS India 1 [2005] Safren (61) Medi- cal charts review, NGO, Chennai304 patients with HIV Self-report of missing doses; Skipping doses at least weekly=irregular (17.8%) Most common reason for non-adherence: 32% (cost)Monthly cost of regi- men: NS Contd. Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy Volume 31 | Number 2 | June 2013 167 Annexure E—Contd.

Country of study, year of publication, first author (Refer- ence number) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence India 2 [2007] Wanchu (62) Cross- sectional study; Chandigarh 200 patients (138 males) receiving generic triple drug reverse transcriptase inhibitor-based an- tiretroviral medica- tions Self-report; 147 did not miss any dose; Fifty-three (26.5%) missed at least one dose during the preceding 4 weeks Bought the medications from their own resourc- es: 35%Non-adherence; Fi- nancial constraints India 3 [2008] Sarna (63) Cross- sectional study 310 patients; 80% first-line Nevirapine- based regimen [160 on Stavudine (D4T)/ Lamivudine (3TC)/ Nevirapine (NVP), and 112 on Zido- vudine (ZDV)/3TC/ NVP)] Self-reported adherence based on a 4-day recall; Mean 4-day adherence was 93% Clients without cover- age were spending on average US$ 66 per month out-of-pocket for their treatment; Em- ployed: 85%; Less than university education:

63%Non-adherence; Free ARV vs paid out of- pocket: AOR=4.05, 1.42–11.54; 5 years education vs University: AOR=4.28, 1.49–12.33 India 4 [2009] Cauldbeck (64) Cross-sec- tional study53 patients Self-reported missing of medications; 19% missed medications in the last week, 30% in the last month 41.5% university educa- tion; 47.7% total family income: 5,000-19,999 Rs/monthEducation level: NS; Family income: NS India 5 [2009] Naik (65) Cross- sectional study; 2 hospitals, Mumbai 152 patients, on ART from 6 months to 5 years Self-reported adherence assessment; 30% missing medication over a week 53% completed high school; 75% had ever missed medication because of the cost of treatmentNon-adherence:

Cost of HAART Contd. Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy JHPN 168 Annexure E—Contd.

33.3%; Monthly in- come: Median US$51.1Education; Free medication India 7 [2010] Lal (67) Cross- sectional study 300 patients Self-report; 75% adherence (not having missed even a single pill over the previ- ous 4-day period) 53.7% employed; 43.7% <5 years of schooling Non-adherence: Pay out-of-pocket for HAART: OR= 7.7, 3.9- 15.1; Education: NS; Employment status:

NS India 8 [2010] Venkatesh (68) Medical chart review data; Chen- nai198 patients on HAART for at least 3 months Self-report from the 30-day visual ana- logue scale in the past month. 31.8% reported 90% HAART adherence in the past month Currently employed:

Men: 94.9%; Women:

45.8% Employment status:

NS Papua New Guinea [2010] Kelly (69) Cross- sectional study, 6 prov- inces in PNG 374 HIV-positive people Self-reported adherence in the past week; 62% complete adherence (no missed or late doses in the past week) Elementary/primary education: 52%; Garden work employment: 42%Education level:

AOR=2.18, 1.05-4.54; Employment type: NS Thailand [2010] Li (70) Cross- sectional study 386 patients Self-report; Among the 121 who reported failing to adhere to ART, 40.5% reported failing to adhere to ART in the past month

84.5%; Personal income:

≤35,000 Baht: 69.2%Education: NS; Em- ployment: NS 95% Confidence intervals; AOR=Adjusted odds ratio; NS=Not significant; OR=Odds ratio; RH=Ris\ k Ratio Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy Volume 31 | Number 2 | June 2013 169 Annexure F. Impact of socioeconomic factors on HAART adherence among adults: study c\ haracteristics (Latin-America and Carribean 1) Country of study, year of publica- tion, first author (Reference number) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence Brazil 1 [2002] Pinheiro (71) Cross- sectional study 195 patients aged 13 years or above Self-reported in the previous 48 h; 56.9% reported ≥95% adherence on the previous two days Years of schooling: Me- dian 5 years; Monthly family income of

30%Non-adherence; 0-2 years of schooling:

AOR=1.48, 1.16-1.89 Brazil 3 [2007] de Carvalho (73) Case-control study105 patients; 35 non-adherent cases; 70 adherent controls Self-reported assessment; 66.7% adher- ent Incomplete primary education: 45.7%; Mean family income: 1587 Brazilian RealEducation: AOR=22.8, 1.9-270.9; Familial income: NS Brazil 4 [2007] Seidl (74) Cross- sectional study 101 HIV+ adults, ranging from 20 to 71 years of age (Mean=37.9 years) Adherence was measured by self-report- ed number of ART pills/capsules missed during the previous week and previous month; 72.3% reported adherence of >95% Incomplete primary education: 26.7% Education: NS Brazil 5 [2009] Blatt (75) Cross- sectional study 67 patients Self-reported dosage forgotten on the last day (70%); in three (76.1%) days; in seven (80.5%) days; and in fifteen (80.5%) days Education (4-7 years):

46.3% Educational level: NS Brazil 5 [2009] Silva (76) Cross- sectional study; outpatient clin- ics of 3 refer- ence hospitals, Recife 412 patients; 67% on ART in previous 3 years Self-reported assessment. 25.7% non- adherence (<90% of the total number of prescribed ART medication in the previous 5 days) Less than 9 years of schooling: 51%; Family income <4 minimum wages: 62%Higher income:

AOR=2.33, 1.17–4.66; 8 years of schooling vs 11 years: NS Contd. Peltzer K and Pengpid S Socioeconomic factors in adherence to HIV therapy JHPN 170 Annexure F—Contd.

Country of study, year of publica- tion, first author (Reference number) Study design, setting Study population, sample-size, type of medication Adherence: measurement, definition, and total adherence Socioeconomic statusImpact of SES on adherence Brazil 6 [2010] Campos ( 77) Longitudinal study; 2 public referral centres, Belo Horizonte293 patients; Mostly two nucle- oside reverse tran- scriptase inhibitors (NRTI) plus one non-nucleoside re- verse transcriptase inhibitor (NNRTI) Self-reported in the past 3 days; The overall cumulative incidence of non- adherence (<95%) was 37.2%, Education <8 years:

49%; No income: 40.3%; Unemployed: 35.1% Non-adherence; Low education: RH=1.71, 1.14-2.56; Unem- ployment: RH=1.90, 1.01-3.57; Monthly income: NS Columbia [2009] Arrivillaga (78) Cross- sectional study, 5 cities 269 women Self-reported 21-item treatment adher- ence questionnaire; 43% of the women presented low (21-61 points on a scale from 21 to 84) adherence to treatment Low social position (residence, SES, educa- tion, type of healthcare plan, occupation profile, income): 80%Non-adherence; Mem- ber of subsidized na- tional healthcare plan, or uninsured: OR=3.45, 1.96–6.18; Low social position: NS Costa Rica [2004] Stout (79) Cross- sectional study 88 patients Self-reported 3-day adherence; 85% reported 100% adherence (not missing any) in the past 3 days Post-secondary educa- tion: 54%; Work for pay:

32%Education level: NS; Work for pay: NS Cuba [2011] Aragonés (80) Cross- sectional study; 25.1% in-pa- tients, 74.9% in ambulatory care 1986 HIV-positive individuals Self-reported number of doses taken in the past three days; 80.6% (≥95.0%) adherent 32.9% high school; 39.2% junior high schoolEducation: NS Dominican Republic [2010] Harris (81) Cross- sectional study 300 patients Self-reported adherence; 24% subopti- mal adherence in the past month Less than high school education: 73%; Em- ployed: 47%Education: NS; Em- ployment status: NS Jamaica [2007] Williams (82) Cross- sectional study 101 patients Self-reported adherence; Mean adher- ence to tablets: 87.7%. Employed: 50.5%; Secondary education:

60.2%Employment status:

NS; Level of education:

NS 95% Confidence intervals; AOR=Adjusted odds ratio; NS=Not significant; OR=Odds ratio; RH=Ris\ k ratio Copyright ofJournal ofHealth, Population, &Nutrition isthe property ofInternational Centre for Diarrhoeal DiseaseResearch, Bangladesh (ICDDR,B) anditscontent maynotbecopied or emailed tomultiple sitesorposted toalistserv without thecopyright holder'sexpress written permission. However,usersmayprint, download, oremail articles forindividual use.