Evolution of ART Medication Adherence Support and Monitoring Across IeDEA Sites: Results From Three Waves of Consortium‐Wide Site Assessment Surveys, 2017, 2020 and 2023

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INTRODUCTION: Since 2013, global HIV treatment guidelines have included recommendations for medication adherence support and monitoring for people on antiretroviral therapy (ART). We examined the implementation of recommended strategies for adherence support and monitoring for adults with HIV through serial cross-sectional structured surveys conducted by the International epidemiology Databases to Evaluate AIDS (IeDEA). METHODS: We used data from surveys completed by HIV clinics across 43 countries in 2017 (n = 206), 2020 (n = 200) and 2023 (n = 214); 131 clinics completed all three surveys. We used descriptive statistics to examine clinic resources and routine adherence support and monitoring at each time point, stratified by country income level (i.e. low/middle-income vs. high-income countries [LMICs/HICs]), and trends among clinics completing all three surveys. We created composite measures of the level or intensity of routine provision of adherence aids/reminders, adherence support and adherence monitoring, ranging from "none" to "enhanced" levels. Among clinics participating in the 2023 survey, we also examined adherence aids and support routinely provided to clients eligible for intensified support versus all clients. RESULTS: At each time point, surveyed clinics were predominantly in LMICs (68.4%-74.3%) and urban settings (65.0%-65.5%), situated within health centres (60.2%-64.0%) or regional/provincial or university hospitals (28.0%-33.5%). Among 131 clinics participating in all surveys, there was a decrease in the provision of multiple adherence readiness counselling sessions from 52.2% of clinics reporting ≥2 sessions before treatment initiation in 2017 to 26.0% in 2023, along with increased provision of 6-month ART refills (from 11.5% to 40.5%). The provision of "enhanced" levels of adherence support to all clients decreased from 2017 to 2023 in both LMICs (64.6% to 28.1%) and HICs (34.3% to 8.6%); in 2023, substantial proportions of clinics reported that such support was routinely provided only to clients eligible for intensive adherence support. At each time point, higher proportions of clinics in LMICs reported "enhanced" adherence monitoring than in HICs (63.5%-70.8% vs. 31.4%-54.3%). CONCLUSIONS: While streamlined provision of ART adherence support may reflect the implementation of guidelines recommending the targeting of support towards clients with known or suspected adherence challenges, further research should examine how evolving clinic adherence support practices are associated with care retention and virologic suppression outcomes.

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