Abstract

This paper aims to evaluate the effectiveness of telephone use for the adherence of people with HIV/AIDS to antiretroviral therapy. A systematic review was carried out in the following databases: Latin American and Caribbean Literature in Health Sciences (Lilacs/ Bireme), SCOPUS, Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Web of Science; and in the Scientific Electronic Library Online (SciELO) and Cochrane libraries, using the following descriptors: “HIV”, “Cell Phones”, “Acquired Immunodeficiency Syndrome” and “Antiretroviral Therapy, Highly Active”. We gathered a sample of 17 papers. The proposed cellphone interventions were the use of cellular applications, Short Message Service, and telephone calls. In most studies, telephone use has had a significant impact on adherence to treatment. The evaluation of the studies showed good methodological quality and adequate allocation secrecy. Self-reported adherence emerged among the adherence measuring methods. Cellphone use was effective in improving adherence to antiretroviral therapy for people living with HIV.

Key words
HIV; Acquired Immunodeficiency Syndrome; Cell phones

Introduction

The advancement of antiretroviral therapy (ART) reduced the morbidity and mortality associated with infection and consequently increased the life expectancy of people living with HIV/AIDS (PLWHA)¹1 Galvão MTG, Soares LL, Pedrosa SC, Fiuza MLT, Lemos LA. Quality of life and adherence to antiretroviral medication in people with HIV. Acta Paulista de Enfermagem 2015; 28(1):48-53.. The effectiveness of ART can only be achieved through good adherence to drugs²2 Silva JAG, Dourado I, Brito AMD, Silva CALD. Factors associated with non-adherence to antiretroviral therapy in adults with AIDS in the first six months of treatment in Salvador, Bahia State, Brazil. Cad Saude Publica 2015; 31(6):1188-1198., in order to prevent viral resistance, the appearance of opportunistic diseases, increased virus transmission, higher probability of developing to the final stage of the disease and the reduced survival³3 Kim J, Zhang W, Nyonyitono M, Lourenço L, Nanfuka M, Okoboi S, Birungi J, Lester RT, Kaleebu P, Munderi P, Moore DM. Feasibility and acceptability of mobile phone short message service as a support for patients receiving antiretroviral therapy in rural Uganda: a cross-sectional study. J Int SIDA Soe 2015; 18(1):20311..

It is a challenge to reach and maintain ideal levels of adherence to ART due to individual, social, and systemic barriers that hamper this process⁴4 Georgette, N, Siedner MJ, Petty CR, Zanoni BC, Carpenter S, Haberer JE. Impact of a clinical program using weekly Short Message Service (SMS) on antiretroviral therapy adherence support in South Africa: a retrospective cohort study. BMC Medical Informatics and Decision Making 2017; 17:18.. Studies indicate that despite the availability of ART drugs, some difficulties concerning adherence to therapy and prevalence rates of non-adherence ranging from 51.3%¹1 Galvão MTG, Soares LL, Pedrosa SC, Fiuza MLT, Lemos LA. Quality of life and adherence to antiretroviral medication in people with HIV. Acta Paulista de Enfermagem 2015; 28(1):48-53.^,55 Harvey KM, Carrington D, Duncan J, Figueroa JP, Hirschorn L, Manning D, Jackson S. Evaluation of adherence to highly active antiretroviral therapy in adults in Jamaica. West Indian Med J 2008; 57(3):293-297. to 25%⁶6 Srivastava S, Pant M, Abraham A, Agrawal N. The Technological Growth in e Health Services. Comput. Math Methods Med 2015; 2015:894171. are observed.

An interest in the use of Information and Communication Technologies (ICTs) has occurred in recent years, and ICTs have had a significant impact on the quality of services and people’s lifestyles. Their implementation in the health sector is emerging as one of the areas with the highest growth rates today. Among the primary technologies are electronic devices such as the telephone, which has gained popularity and stands out as a strong ally in the treatment of chronic diseases⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161..

In the context of HIV/AIDS, studies have shown the advantages of using the telephone to improve care services for this population, with impacts on improving quality of life, social support, self-care⁸8 Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball T, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1):a randomised trial. The Lancet 2010; 376 (9755):1838-1845.^,99 Pop-eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, DeWalque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011; 25(6):825-834. and adherence to ART⁸8 Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball T, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1):a randomised trial. The Lancet 2010; 376 (9755):1838-1845.^,1010 Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013; 16(3):302-308.

11 Haberer JE, Musiimenta A, Atukunda EC, Musinguzi N, Wyatt MA, Ware NC, Bangsberg DR. Short message service (SMS) reminders and real-time adherence monitoring improve antiretroviral therapy adherence in rural Uganda. AIDS 2016; 30(8):1295-1299.^-1212 Mills EJ, Lester R, Thorlund K, Lorenzi M, Muldoon K, Kanters S, Linnemayr S, Gross R, Calderone Y, Amico KR, Thirumurthy H, Pearson C, Remien RH, Mbuagbaw L, Thabane L, Chung MH, Wilson IB, Liu A, Uthman OA, Simoni J, Bangsberg D, Yaya S, Barnighausen T, Stirrat MJ, Ford N, Nachega JB. Interventions to promote adherence to antiretroviral therapy in Africa: a network meta-analysis. Lancet HIV. [Internet]. 2014[accessed 2017 Nov 30]; 1(3):e104-11. Available at: http://doi.org/10.1016/S2352-3018(14)00003-4.
http://doi.org/10.1016/S2352-3018(14)000... .

Thus, the development of efficient methods to improve adherence of people with HIV/AIDS to ART is required. In this context, telephone use can be an available resource to promote adherence to PLWHA treatment since it is inexpensive and easily accessible among patients and health professionals. Therefore, this study aimed to evaluate the effectiveness of telephone use for the adherence of people with HIV/AIDS to antiretroviral therapy.

Methods

A systematic review was carried out, a secondary study type that allows the investigation of relevant research on a particular theme in order to undertake a critical and comprehensive review of the literature, providing the incorporation of new trends in clinical practice and the consequent evidence-based refreshing of professionals¹³13 Clarke M. Cochrane Collaboration. In: Armitage P, Colton T, editors. Encyclopedia of Biostatistics. 2(nd) edition. Chichester: John Wiley & Sons; 2005.[informar as páginas do capítulo].

The systematic review followed the seven steps recommended by Cochrane collaboration¹⁴14 Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0. The Cochrane Collaboration 2011. [accessed 2017 Nov 30]. Available at: www.cochrane-handbook.org
www.cochrane-handbook.org... : formulation of the research question; study sites; critical evaluation of research; data collection; analysis and presentation of information.

The research question was outlined from the PICO strategy, which is an acronym for Patient (adults living with HIV), Intervention (Use of the telephone), Comparison (standard care) and Outcomes (treatment adherence)⁸8 Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball T, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1):a randomised trial. The Lancet 2010; 376 (9755):1838-1845.. Thus, the following guiding question was established: “How effective is telephone use to promote PLWHA adherence to ART?”

We included clinical trials that investigated interventions with telephone use aimed at promoting adherence of PLWHA to ART regardless of language and year of publication. The exclusion criteria defined were: literature reviews, letters, opinion papers, experience reports, case studies, book chapters, congress presentations, repeated publications, studies with children and papers that did not respond to the research question.

The electronic search was performed by two reviewers simultaneously in October 2017, in three databases - Latin American and Caribbean Literature in Health Sciences (LILACS/BIREME), SCOPUS and Web of Science; portal Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed) and the Scientific Electronic Library Online (SciELO) and Cochrane libraries.

The search strategy employed the following descriptors in Portuguese, English, and Spanish: “HIV”, “Cell Phones”, “Acquired Immunodeficiency Syndrome” and “Antiretroviral Therapy, Highly Active”, combined with the Boolean operator AND in Portuguese, English, and Spanish. Descriptors were selected using the Health Sciences Descriptors (DeCS) and the Medical Subject Heading (MeSH). Cross-linkings were: [HIV and Cell Phones]; [Acquired Immunodeficiency Syndrome and Cell Phones]; [Antiretroviral Therapy, Highly Active and Cell Phones]; [HIV and Cell Phones and Antiretroviral Therapy, Highly Active]; [Acquired Immunodeficiency Syndrome and Cell Phones and Antiretroviral Therapy, Highly Active].

A total of 758 papers were found from cross-linkings, and 17 were selected. Of these, 29 were duplicated, and 712 did not answer the guiding question because they addressed the following topics: acceptance of the proposed interventions, perceptions of the individuals about the interventions, reflections on advances in the use of technologies to improve adherence. The final sample consisted of 17 papers, six from SCOPUS, five from MEDLINE/PubMed, three from Web of Science and three from Cochrane. Figure 1 shows the identification, selection, and inclusion of research papers.

The criteria for evaluating the quality of the studies were carried out by applying the Jadad’s Quality Scale¹⁵15 Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin. Trials 1996; 17(1):1-12., whose scores range from 0 to 5, with low-quality studies scoring below three. The analysis was performed from the following questions: 1a. Was the study described as random? (use of words such as “randomized”, “random”, “randomization”); 1b. Was the method adequate? 2a. Was the study described as double-blind? 2b. Was the method adequate? 3. Was there a description of the losses and exclusions?

Papers were also analyzed and classified concerning allocation secrecy into Category A - allocation secrecy adequately carried out and described; Category B - the study was described as random, but the randomization method or of the allocation secrecy are not described; Category C - the allocation secrecy was inappropriate; and Category D - the study was not random¹⁴14 Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0. The Cochrane Collaboration 2011. [accessed 2017 Nov 30]. Available at: www.cochrane-handbook.org
www.cochrane-handbook.org... .

Data were analyzed by two independent authors, translating and reading the papers in full. The information was transcribed and organized from a validated instrument¹⁶16 Ursi ES, Galvão CM. Prevenção de lesões de pele no perioperatório: revisão integrativa da literatura. Rev Latino-am Enfermagem 2006; 14(1):124-131., which investigated authorship, year, the country where the study was conducted, objective, methodological development, proposed technology, results, and conclusion. Therefore, we opted for a detailed review of the information found.

Regarding ethical issues, paper integrity and copyright were respected, and there was no change in the content found for the benefit of this research.

Results

All studies consisted of clinical trials and covered a total of 2,720 adults with HIV using ART, published from 2010 to 2017. Most studies were conducted in the U.S.⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.^,1717 Dowshen N, Kuhns LM, Johnson A, Holoyda BJ, Garofalo R. Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders. J Med Internet Res 2012; 14(2):e51.

18 Kalichman SC, Kalichman MO, Cherry C, Swetzes C, Amaral CM, White D, Jones M, Grebler T, Eaton L. Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial. AIDS Patient Care STDS 2011; 25(5):303-310.

19 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.

20 Swendeman D, Jana S, Ray P, Mindry D, Das M, Bhakta B. Development and Pilot Testing of Daily Interactive Voice Response (IVR) Calls to Support Antiretroviral Adherence in India: A Mixed-Methods Pilot Study. AIDS Behav 2015; 2(19 Supl.):142-155.

21 Rana AI, Van den Berg JJ, Lamy E, Beckwith CG. Using a Mobile Health Intervention to Support HIV Treatment Adherence and Retention Among Patients at Risk for Disengaging with Care. AIDS Patient Care STDS 2016; 30(4):178-184.^-2222 Garofalo R, Kuhns LM, Hotton A, Johnson A, Muldoon A, Rice D. A randomized controlled trial of personalized text message reminders to promote medication adherence among HIV-positive adolescents and young adults. AIDS and Behavior. 2016; 20(5):1049-1059., as well as African countries, such as Kenya⁸8 Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball T, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1):a randomised trial. The Lancet 2010; 376 (9755):1838-1845.^-99 Pop-eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, DeWalque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011; 25(6):825-834., Uganda²³23 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586., South Africa²⁴24 Orrell C, Cohen K, Mauff K, Bangsberg DR, Maartens G, Wood R. A randomized controlled trial of real-time electronic adherence monitoring with text message dosing reminders in people starting first-line antiretroviral therapy. J Acquir Immune Defic Syndr 2015; 70(5):495-502. and Nigeria¹⁰10 Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013; 16(3):302-308., Asian countries²⁵25 Sabin LL, Bachman DSM, Gill CJ, Zhong L, Vian T, Xie W, Cheng F, Xu K, Lan G, Haberer JE, Bangsberg DR, Li Y, Lu H, Gifford AL. Improving Adherence to Antiretroviral Therapy With Triggered Real-time Text Message Reminders: The China Adherence Through Technology Study. J Acquir Immune Defic Syndr 2015; 69(5):551-559.

26 Shet A, De Costa A, Kumarasamy N, Rodrigues R, Rewari BB, Ashorn P, Eriksson B, Diwan V. Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India. BMJ 2014; 349:g5978.

27 Swendeman D, Comulada WS, Ramanathan N, Lazar M, Estrin D. Reliability and Validity of Daily Self-Monitoring by Smartphone Application for Health-Related Quality-of-Life, Antiretroviral Adherence, Substance Use, and Sexual Behaviors Among People Living with HIV. AIDS Behav 2015; 19(2):330-340.^-2828 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698., and Brazil²⁹29 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269. (Chart 1). The interventions proposed were use of cellphone applications²⁰20 Swendeman D, Jana S, Ray P, Mindry D, Das M, Bhakta B. Development and Pilot Testing of Daily Interactive Voice Response (IVR) Calls to Support Antiretroviral Adherence in India: A Mixed-Methods Pilot Study. AIDS Behav 2015; 2(19 Supl.):142-155.^,2323 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586., Short Message Service (SMS)⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.

8 Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball T, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1):a randomised trial. The Lancet 2010; 376 (9755):1838-1845.

9 Pop-eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, DeWalque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011; 25(6):825-834.^-1010 Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013; 16(3):302-308.^,1717 Dowshen N, Kuhns LM, Johnson A, Holoyda BJ, Garofalo R. Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders. J Med Internet Res 2012; 14(2):e51.^,2121 Rana AI, Van den Berg JJ, Lamy E, Beckwith CG. Using a Mobile Health Intervention to Support HIV Treatment Adherence and Retention Among Patients at Risk for Disengaging with Care. AIDS Patient Care STDS 2016; 30(4):178-184.^,2222 Garofalo R, Kuhns LM, Hotton A, Johnson A, Muldoon A, Rice D. A randomized controlled trial of personalized text message reminders to promote medication adherence among HIV-positive adolescents and young adults. AIDS and Behavior. 2016; 20(5):1049-1059.^,2424 Orrell C, Cohen K, Mauff K, Bangsberg DR, Maartens G, Wood R. A randomized controlled trial of real-time electronic adherence monitoring with text message dosing reminders in people starting first-line antiretroviral therapy. J Acquir Immune Defic Syndr 2015; 70(5):495-502.

25 Sabin LL, Bachman DSM, Gill CJ, Zhong L, Vian T, Xie W, Cheng F, Xu K, Lan G, Haberer JE, Bangsberg DR, Li Y, Lu H, Gifford AL. Improving Adherence to Antiretroviral Therapy With Triggered Real-time Text Message Reminders: The China Adherence Through Technology Study. J Acquir Immune Defic Syndr 2015; 69(5):551-559.

26 Shet A, De Costa A, Kumarasamy N, Rodrigues R, Rewari BB, Ashorn P, Eriksson B, Diwan V. Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India. BMJ 2014; 349:g5978.

27 Swendeman D, Comulada WS, Ramanathan N, Lazar M, Estrin D. Reliability and Validity of Daily Self-Monitoring by Smartphone Application for Health-Related Quality-of-Life, Antiretroviral Adherence, Substance Use, and Sexual Behaviors Among People Living with HIV. AIDS Behav 2015; 19(2):330-340.

28 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698.^-2929 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269. and telephone calls¹⁸18 Kalichman SC, Kalichman MO, Cherry C, Swetzes C, Amaral CM, White D, Jones M, Grebler T, Eaton L. Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial. AIDS Patient Care STDS 2011; 25(5):303-310.^,1919 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.^,2626 Shet A, De Costa A, Kumarasamy N, Rodrigues R, Rewari BB, Ashorn P, Eriksson B, Diwan V. Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India. BMJ 2014; 349:g5978.^,2828 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698. (Chart 1).

The use of the application consisted of a program installed in the cellphone with several features such as a clock with the 24-hour drug, showing the schedule of the daily dose of the participant’s therapy, which recorded the days and times of drug intake; graphical representations of the estimated plasma concentrations of each ART drug; and a simulation of immune activity comprising a representation of the CD4 + T lymphocyte count and viral load, based on the most recent blood tests. This application allowed the participants’ real-time visualization of the physiological effects of their adherence to ART¹⁹19 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.^,2929 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269..

The SMS consisted of text messages sent from cellphones. The content of the message was motivating and worked as a reminder to take the ART drugs and influenced behaviors to improve adherence²⁹29 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269.. In one study, participants should confirm receipt of the message; otherwise, a beep would be sent every 15 minutes to the patient⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161..

The intervention based on telephone calls was directed to the users’ portable devices and aimed to investigate the medication intake and possible missed doses in the last days, as well as provide advice to promote adherence¹⁸18 Kalichman SC, Kalichman MO, Cherry C, Swetzes C, Amaral CM, White D, Jones M, Grebler T, Eaton L. Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial. AIDS Patient Care STDS 2011; 25(5):303-310..

Follow-up time ranged from 4 (one month) to 96 (24 months) weeks. Improved adherence was identified in fourteen studies⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.

8 Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball T, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1):a randomised trial. The Lancet 2010; 376 (9755):1838-1845.

9 Pop-eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, DeWalque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011; 25(6):825-834.^-1010 Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013; 16(3):302-308.^,1717 Dowshen N, Kuhns LM, Johnson A, Holoyda BJ, Garofalo R. Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders. J Med Internet Res 2012; 14(2):e51.^,2121 Rana AI, Van den Berg JJ, Lamy E, Beckwith CG. Using a Mobile Health Intervention to Support HIV Treatment Adherence and Retention Among Patients at Risk for Disengaging with Care. AIDS Patient Care STDS 2016; 30(4):178-184.

22 Garofalo R, Kuhns LM, Hotton A, Johnson A, Muldoon A, Rice D. A randomized controlled trial of personalized text message reminders to promote medication adherence among HIV-positive adolescents and young adults. AIDS and Behavior. 2016; 20(5):1049-1059.

23 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586.^-2424 Orrell C, Cohen K, Mauff K, Bangsberg DR, Maartens G, Wood R. A randomized controlled trial of real-time electronic adherence monitoring with text message dosing reminders in people starting first-line antiretroviral therapy. J Acquir Immune Defic Syndr 2015; 70(5):495-502.^,2727 Swendeman D, Comulada WS, Ramanathan N, Lazar M, Estrin D. Reliability and Validity of Daily Self-Monitoring by Smartphone Application for Health-Related Quality-of-Life, Antiretroviral Adherence, Substance Use, and Sexual Behaviors Among People Living with HIV. AIDS Behav 2015; 19(2):330-340.

28 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698.^-2929 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269., and interventions were ineffective in three of them²⁰20 Swendeman D, Jana S, Ray P, Mindry D, Das M, Bhakta B. Development and Pilot Testing of Daily Interactive Voice Response (IVR) Calls to Support Antiretroviral Adherence in India: A Mixed-Methods Pilot Study. AIDS Behav 2015; 2(19 Supl.):142-155.^,2525 Sabin LL, Bachman DSM, Gill CJ, Zhong L, Vian T, Xie W, Cheng F, Xu K, Lan G, Haberer JE, Bangsberg DR, Li Y, Lu H, Gifford AL. Improving Adherence to Antiretroviral Therapy With Triggered Real-time Text Message Reminders: The China Adherence Through Technology Study. J Acquir Immune Defic Syndr 2015; 69(5):551-559.^,2626 Shet A, De Costa A, Kumarasamy N, Rodrigues R, Rewari BB, Ashorn P, Eriksson B, Diwan V. Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India. BMJ 2014; 349:g5978..

Concerning the frequency of intervention, daily frequency prevailed⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.^,1717 Dowshen N, Kuhns LM, Johnson A, Holoyda BJ, Garofalo R. Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders. J Med Internet Res 2012; 14(2):e51.^,1919 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.

20 Swendeman D, Jana S, Ray P, Mindry D, Das M, Bhakta B. Development and Pilot Testing of Daily Interactive Voice Response (IVR) Calls to Support Antiretroviral Adherence in India: A Mixed-Methods Pilot Study. AIDS Behav 2015; 2(19 Supl.):142-155.

21 Rana AI, Van den Berg JJ, Lamy E, Beckwith CG. Using a Mobile Health Intervention to Support HIV Treatment Adherence and Retention Among Patients at Risk for Disengaging with Care. AIDS Patient Care STDS 2016; 30(4):178-184.

22 Garofalo R, Kuhns LM, Hotton A, Johnson A, Muldoon A, Rice D. A randomized controlled trial of personalized text message reminders to promote medication adherence among HIV-positive adolescents and young adults. AIDS and Behavior. 2016; 20(5):1049-1059.

23 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586.

24 Orrell C, Cohen K, Mauff K, Bangsberg DR, Maartens G, Wood R. A randomized controlled trial of real-time electronic adherence monitoring with text message dosing reminders in people starting first-line antiretroviral therapy. J Acquir Immune Defic Syndr 2015; 70(5):495-502.^-2525 Sabin LL, Bachman DSM, Gill CJ, Zhong L, Vian T, Xie W, Cheng F, Xu K, Lan G, Haberer JE, Bangsberg DR, Li Y, Lu H, Gifford AL. Improving Adherence to Antiretroviral Therapy With Triggered Real-time Text Message Reminders: The China Adherence Through Technology Study. J Acquir Immune Defic Syndr 2015; 69(5):551-559.^,2727 Swendeman D, Comulada WS, Ramanathan N, Lazar M, Estrin D. Reliability and Validity of Daily Self-Monitoring by Smartphone Application for Health-Related Quality-of-Life, Antiretroviral Adherence, Substance Use, and Sexual Behaviors Among People Living with HIV. AIDS Behav 2015; 19(2):330-340.. Three studies used frequency on alternate days⁸8 Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball T, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1):a randomised trial. The Lancet 2010; 376 (9755):1838-1845.^,1010 Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013; 16(3):302-308.^,2929 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269., two were weekly²⁶26 Shet A, De Costa A, Kumarasamy N, Rodrigues R, Rewari BB, Ashorn P, Eriksson B, Diwan V. Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India. BMJ 2014; 349:g5978.^,2828 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698., one fortnightly¹⁸18 Kalichman SC, Kalichman MO, Cherry C, Swetzes C, Amaral CM, White D, Jones M, Grebler T, Eaton L. Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial. AIDS Patient Care STDS 2011; 25(5):303-310., and another study compared the use of daily and weekly intervention⁹9 Pop-eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, DeWalque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011; 25(6):825-834.. As for the professionals who applied the intervention, the study team with unspecified professional category was highlighted (82.3%)⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.^,99 Pop-eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, DeWalque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011; 25(6):825-834.^,1010 Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013; 16(3):302-308.^,1717 Dowshen N, Kuhns LM, Johnson A, Holoyda BJ, Garofalo R. Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders. J Med Internet Res 2012; 14(2):e51.^,1818 Kalichman SC, Kalichman MO, Cherry C, Swetzes C, Amaral CM, White D, Jones M, Grebler T, Eaton L. Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial. AIDS Patient Care STDS 2011; 25(5):303-310.^,2020 Swendeman D, Jana S, Ray P, Mindry D, Das M, Bhakta B. Development and Pilot Testing of Daily Interactive Voice Response (IVR) Calls to Support Antiretroviral Adherence in India: A Mixed-Methods Pilot Study. AIDS Behav 2015; 2(19 Supl.):142-155.^,2222 Garofalo R, Kuhns LM, Hotton A, Johnson A, Muldoon A, Rice D. A randomized controlled trial of personalized text message reminders to promote medication adherence among HIV-positive adolescents and young adults. AIDS and Behavior. 2016; 20(5):1049-1059.

23 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586.

24 Orrell C, Cohen K, Mauff K, Bangsberg DR, Maartens G, Wood R. A randomized controlled trial of real-time electronic adherence monitoring with text message dosing reminders in people starting first-line antiretroviral therapy. J Acquir Immune Defic Syndr 2015; 70(5):495-502.^-2525 Sabin LL, Bachman DSM, Gill CJ, Zhong L, Vian T, Xie W, Cheng F, Xu K, Lan G, Haberer JE, Bangsberg DR, Li Y, Lu H, Gifford AL. Improving Adherence to Antiretroviral Therapy With Triggered Real-time Text Message Reminders: The China Adherence Through Technology Study. J Acquir Immune Defic Syndr 2015; 69(5):551-559.^,2727 Swendeman D, Comulada WS, Ramanathan N, Lazar M, Estrin D. Reliability and Validity of Daily Self-Monitoring by Smartphone Application for Health-Related Quality-of-Life, Antiretroviral Adherence, Substance Use, and Sexual Behaviors Among People Living with HIV. AIDS Behav 2015; 19(2):330-340.^,2929 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269., followed by researchers who were not involved in the routine of the patients (5.8%)²⁶26 Shet A, De Costa A, Kumarasamy N, Rodrigues R, Rewari BB, Ashorn P, Eriksson B, Diwan V. Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India. BMJ 2014; 349:g5978., as well as the mention of higher education health categories, such as nurses (11.8%)⁸8 Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball T, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1):a randomised trial. The Lancet 2010; 376 (9755):1838-1845.^,2828 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698. and doctors (5.8%)²⁸28 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698. (Chart 1).

Regarding methods for measuring ART adherence, self-reported adherence⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.^,88 Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball T, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1):a randomised trial. The Lancet 2010; 376 (9755):1838-1845.^,1010 Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013; 16(3):302-308.^,1717 Dowshen N, Kuhns LM, Johnson A, Holoyda BJ, Garofalo R. Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders. J Med Internet Res 2012; 14(2):e51.

18 Kalichman SC, Kalichman MO, Cherry C, Swetzes C, Amaral CM, White D, Jones M, Grebler T, Eaton L. Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial. AIDS Patient Care STDS 2011; 25(5):303-310.

19 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.^-2020 Swendeman D, Jana S, Ray P, Mindry D, Das M, Bhakta B. Development and Pilot Testing of Daily Interactive Voice Response (IVR) Calls to Support Antiretroviral Adherence in India: A Mixed-Methods Pilot Study. AIDS Behav 2015; 2(19 Supl.):142-155.^,2222 Garofalo R, Kuhns LM, Hotton A, Johnson A, Muldoon A, Rice D. A randomized controlled trial of personalized text message reminders to promote medication adherence among HIV-positive adolescents and young adults. AIDS and Behavior. 2016; 20(5):1049-1059.^,2323 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586.^,2626 Shet A, De Costa A, Kumarasamy N, Rodrigues R, Rewari BB, Ashorn P, Eriksson B, Diwan V. Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India. BMJ 2014; 349:g5978.

27 Swendeman D, Comulada WS, Ramanathan N, Lazar M, Estrin D. Reliability and Validity of Daily Self-Monitoring by Smartphone Application for Health-Related Quality-of-Life, Antiretroviral Adherence, Substance Use, and Sexual Behaviors Among People Living with HIV. AIDS Behav 2015; 19(2):330-340.

28 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698.^-2929 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269., the drug monitoring system (MEMS)⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.^,99 Pop-eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, DeWalque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011; 25(6):825-834.^,2121 Rana AI, Van den Berg JJ, Lamy E, Beckwith CG. Using a Mobile Health Intervention to Support HIV Treatment Adherence and Retention Among Patients at Risk for Disengaging with Care. AIDS Patient Care STDS 2016; 30(4):178-184.^,2525 Sabin LL, Bachman DSM, Gill CJ, Zhong L, Vian T, Xie W, Cheng F, Xu K, Lan G, Haberer JE, Bangsberg DR, Li Y, Lu H, Gifford AL. Improving Adherence to Antiretroviral Therapy With Triggered Real-time Text Message Reminders: The China Adherence Through Technology Study. J Acquir Immune Defic Syndr 2015; 69(5):551-559.^,2929 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269. the tablet count⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.^,1818 Kalichman SC, Kalichman MO, Cherry C, Swetzes C, Amaral CM, White D, Jones M, Grebler T, Eaton L. Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial. AIDS Patient Care STDS 2011; 25(5):303-310.^,2929 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269., the composite adherence score⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161., the pharmacy records¹⁹19 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.^,2525 Sabin LL, Bachman DSM, Gill CJ, Zhong L, Vian T, Xie W, Cheng F, Xu K, Lan G, Haberer JE, Bangsberg DR, Li Y, Lu H, Gifford AL. Improving Adherence to Antiretroviral Therapy With Triggered Real-time Text Message Reminders: The China Adherence Through Technology Study. J Acquir Immune Defic Syndr 2015; 69(5):551-559., the CD4+ T lymphocyte count¹⁰10 Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013; 16(3):302-308.^,2828 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698. and the evaluation of the viral load¹⁹19 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.^,2222 Garofalo R, Kuhns LM, Hotton A, Johnson A, Muldoon A, Rice D. A randomized controlled trial of personalized text message reminders to promote medication adherence among HIV-positive adolescents and young adults. AIDS and Behavior. 2016; 20(5):1049-1059.

23 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586.^-2424 Orrell C, Cohen K, Mauff K, Bangsberg DR, Maartens G, Wood R. A randomized controlled trial of real-time electronic adherence monitoring with text message dosing reminders in people starting first-line antiretroviral therapy. J Acquir Immune Defic Syndr 2015; 70(5):495-502.^,2828 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698. were highlighted. Some studies were submitted to a combination of different forms of measuring adherence⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.^,1010 Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013; 16(3):302-308.^,1717 Dowshen N, Kuhns LM, Johnson A, Holoyda BJ, Garofalo R. Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders. J Med Internet Res 2012; 14(2):e51.

18 Kalichman SC, Kalichman MO, Cherry C, Swetzes C, Amaral CM, White D, Jones M, Grebler T, Eaton L. Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial. AIDS Patient Care STDS 2011; 25(5):303-310.^-1919 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.^,2222 Garofalo R, Kuhns LM, Hotton A, Johnson A, Muldoon A, Rice D. A randomized controlled trial of personalized text message reminders to promote medication adherence among HIV-positive adolescents and young adults. AIDS and Behavior. 2016; 20(5):1049-1059.^,2323 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586.^,2828 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698.^,2929 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269. (Chart 1).

In self-reported adherence, patients reported the prescribed medication, drugs ingested, and the number of doses missed in the last days²⁹29 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269.. Other papers analyzed adherence through the use of instruments such as Medication Adherence Report Scale (MARS), which consists of specific questions about the dose ingested and doses missed in the last 28 days, organized on a Likert scale²³23 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586.; and the Visual Analogue Scale (VAS), which analyzes the rate of adherence in the last 4 weeks on a scale from 0% to 100%, correlating with the tablet count recalled in the last three days and the viral load¹⁷17 Dowshen N, Kuhns LM, Johnson A, Holoyda BJ, Garofalo R. Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders. J Med Internet Res 2012; 14(2):e51..

MEMS was also a strategy used to measure adherence and consists of a wireless device placed in the medication container that records the date and time of each opening of the vial for antiretroviral ingestion, communicating immediately through a radio service to a central server²⁵25 Sabin LL, Bachman DSM, Gill CJ, Zhong L, Vian T, Xie W, Cheng F, Xu K, Lan G, Haberer JE, Bangsberg DR, Li Y, Lu H, Gifford AL. Improving Adherence to Antiretroviral Therapy With Triggered Real-time Text Message Reminders: The China Adherence Through Technology Study. J Acquir Immune Defic Syndr 2015; 69(5):551-559..

Other studies measured adherence by counting tablets, delivering the medication at an initial meeting, and counting tablets at the end of a given period²⁸28 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698.. The composite adherence score (CAS) was also adopted, which is a method based on both the tablet count and MEMS⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161..

Pharmacy replenishment records were an additional method of assessing adherence, providing information on the number of tablets released to patients, and calculation of prescribed tablets, taking into account the number of tablets dispensed²³23 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586.. The CD4+ T lymphocytes¹⁰10 Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013; 16(3):302-308.^,2828 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698. and viral load were also measured by laboratory tests¹⁹19 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.^,2323 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586..

Chart 2 shows the characterization of the studies by author, year and country of publication, sample, intervention used, follow-up time, results concerning the improvement of adherence, the Jadad’s scale score and allocation secrecy.

The evaluation of the quality of the studies shows good methodological quality, with a predominance of scores higher than 3⁹9 Pop-eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, DeWalque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011; 25(6):825-834.^,1010 Maduka O, Tobin-West CI. Adherence counseling and reminder text messages improve uptake of antiretroviral therapy in a tertiary hospital in Nigeria. Niger J Clin Pract 2013; 16(3):302-308.^,1818 Kalichman SC, Kalichman MO, Cherry C, Swetzes C, Amaral CM, White D, Jones M, Grebler T, Eaton L. Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial. AIDS Patient Care STDS 2011; 25(5):303-310.

19 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.^-2020 Swendeman D, Jana S, Ray P, Mindry D, Das M, Bhakta B. Development and Pilot Testing of Daily Interactive Voice Response (IVR) Calls to Support Antiretroviral Adherence in India: A Mixed-Methods Pilot Study. AIDS Behav 2015; 2(19 Supl.):142-155.^,2222 Garofalo R, Kuhns LM, Hotton A, Johnson A, Muldoon A, Rice D. A randomized controlled trial of personalized text message reminders to promote medication adherence among HIV-positive adolescents and young adults. AIDS and Behavior. 2016; 20(5):1049-1059.^,2424 Orrell C, Cohen K, Mauff K, Bangsberg DR, Maartens G, Wood R. A randomized controlled trial of real-time electronic adherence monitoring with text message dosing reminders in people starting first-line antiretroviral therapy. J Acquir Immune Defic Syndr 2015; 70(5):495-502.

25 Sabin LL, Bachman DSM, Gill CJ, Zhong L, Vian T, Xie W, Cheng F, Xu K, Lan G, Haberer JE, Bangsberg DR, Li Y, Lu H, Gifford AL. Improving Adherence to Antiretroviral Therapy With Triggered Real-time Text Message Reminders: The China Adherence Through Technology Study. J Acquir Immune Defic Syndr 2015; 69(5):551-559.^-2626 Shet A, De Costa A, Kumarasamy N, Rodrigues R, Rewari BB, Ashorn P, Eriksson B, Diwan V. Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India. BMJ 2014; 349:g5978.^,2828 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698.^,2929 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269.. Regarding the allocation secrecy, there was an emphasis on Category A - adequate allocation secrecy process, except for four studies whose allocation secrecy was not described⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.^,99 Pop-eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, DeWalque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011; 25(6):825-834.^,1919 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.^,2020 Swendeman D, Jana S, Ray P, Mindry D, Das M, Bhakta B. Development and Pilot Testing of Daily Interactive Voice Response (IVR) Calls to Support Antiretroviral Adherence in India: A Mixed-Methods Pilot Study. AIDS Behav 2015; 2(19 Supl.):142-155. and two that were not random¹⁷17 Dowshen N, Kuhns LM, Johnson A, Holoyda BJ, Garofalo R. Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders. J Med Internet Res 2012; 14(2):e51.^,2727 Swendeman D, Comulada WS, Ramanathan N, Lazar M, Estrin D. Reliability and Validity of Daily Self-Monitoring by Smartphone Application for Health-Related Quality-of-Life, Antiretroviral Adherence, Substance Use, and Sexual Behaviors Among People Living with HIV. AIDS Behav 2015; 19(2):330-340. (Chart 2).

Discussion

The use of ICTs in the context of HIV increases access to health services and promotes communication between the professional and the patient on a real-time basis, providing self-care and disease management. The efficacy of these technologies on adherence to ART is associated with providing social support, patient self-assessment about therapeutic follow-up, knowledge about HIV, and management of side effects - conditions that help the patient to establish a daily routine and to solve problems related to taking tablets³⁰30 Rodrigues R, Poongulali S, Balaji K, Atkins S, Ashorn P, Costa ADE. Patient perceptions of an mHealth antiretroviral treatment support intervention in the HIVIND trial in South India. BMJ Abrir 2015; 5(11):e007574..

Real-time ICT professional follow-up promotes information and education for adherence, allowing patients to report side effects and quickly adjust their behavior to improve adherence. Also, the use of technologies as a reminder to take ART drugs as per medical prescription improves the drug dose self-management behavior²⁵25 Sabin LL, Bachman DSM, Gill CJ, Zhong L, Vian T, Xie W, Cheng F, Xu K, Lan G, Haberer JE, Bangsberg DR, Li Y, Lu H, Gifford AL. Improving Adherence to Antiretroviral Therapy With Triggered Real-time Text Message Reminders: The China Adherence Through Technology Study. J Acquir Immune Defic Syndr 2015; 69(5):551-559..

Technology-mediated health care is seen as a ubiquitous glance and permanent attention of professionals concerning the daily life of PLWHA, motivating adherence to treatment behavior, and promoting emotional support to fight against diagnosis-related depressive feelings³¹31 Ware NC, Pisarski EE, Tam M, Wyatt MA, Atukunda E, Musiimenta A, Bangsberg DR, Haberer JE. The Meanings in the messages: how SMS reminders and real-time adherence monitoring improve antiretroviral therapy adherence in rural Uganda. AIDS 2016; 30(8):1287-1293.. Thus, frequent communication between professional and patient works as direct counseling, promoting time, and financial costs savings³¹31 Ware NC, Pisarski EE, Tam M, Wyatt MA, Atukunda E, Musiimenta A, Bangsberg DR, Haberer JE. The Meanings in the messages: how SMS reminders and real-time adherence monitoring improve antiretroviral therapy adherence in rural Uganda. AIDS 2016; 30(8):1287-1293.^,3232 Van der Kop ML, Karanja S, Thabane L, Marra C, Chung MH, Gelmon L, Kimani J, Lester RT. In-depth analysis of patient-clinician cell phone communication during the WelTel Kenya1 antiretroviral adherence trial. PLoS One 2012; 7(9):e46033..

As evidenced in this review, the use of technologies to extend health care to PLWHA brings beneficial impacts in the short and long term, promotes viral suppression, prevents disease progression, and reduces drug resistance and morbimortality. It is emphasized that an intervention time of at least six months is recommended²⁸28 Abdulrahman SA, Rampal L, Ibrahim F, Radhakrishnan AP, Shahar HK, Othman N. Mobile phone reminders and peer counseling improve adherence and treatment outcomes of patients on ART in Malaysia: A randomized clinical trial. PloS one 2017; 12(5):e0177698. in order to achieve positive results on biological markers.

Despite the advantages associated with the use of technologies to promote adherence to ART, some difficulties may compromise cell phone use in health care, such as the lack of credits, handling difficulty, keeping the battery charged, network problems, loss of access, change of number, restricted time of telephone use, breach of confidentiality and concern with the disclosure of the serological status to third parties⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.^,3232 Van der Kop ML, Karanja S, Thabane L, Marra C, Chung MH, Gelmon L, Kimani J, Lester RT. In-depth analysis of patient-clinician cell phone communication during the WelTel Kenya1 antiretroviral adherence trial. PLoS One 2012; 7(9):e46033.^,3333 RanaY, HabererJ, Huang H, Kambugu A , Mukasa B , Thirumurthy H, Wabukala P, Wagner GJ, Linnemayr S. Short Message Service (SMS)-Based Intervention to Improve Treatment Adherence among HIV-Positive Youth in Uganda: Focus Group Findings. PLoS One 2015; 10(4):e0125187..

Given the above, it is necessary to develop intervention strategies that are inexpensive, effective, and that seek to involve the patient with the health service³⁴34 Mûnene E, Ekman B. Association between patient engagement in HIV care and antiretroviral therapy medication adherence: cross-sectional evidence from a regional HIV care center in Kenya. AIDS Care 2015; 27(3):378-386.. Also, it is essential to know the patients’ perceptions and needs vis-à-vis these technologies, identifying the barriers and solving the problems to seek the development of effective technologies¹⁹19 Belzer ME, Naar-King S, Olson J, Sarr M, Thornton S, Kahana SY, Gaur AH, Clark LF. The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial. AIDS Behav 2014; 18(4):686-696.. It is, therefore, necessary to compare technologies and seek the most appropriate ones for each context.

Regarding the frequency of intervention, the weekly messages were more widely accepted and caused more significant impact and better adherence to ART when compared to daily reminders. This can be explained by the frequent and repeated stimulation that causes discomfort in the patients and may invade their privacy⁹9 Pop-eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, DeWalque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011; 25(6):825-834..

Regarding the adherence measurement methods, self-reported adherence, which is less expensive and more comfortable to analyze, but subjective and error-prone and may result in overestimated values³⁵35 Gare J, Kelly-Hanku A, Ryan CE, David M, Kaima P, Imara U, Lote N, Crowe SM, Hearps AC. Factors Influencing Antiretroviral Adherence and Virological Outcomes in People Living with HIV in the Highlands of Papua New Guinea. PLoS One 2015; 10:8. prevailed. Thus, one must associate these self-reported measures with clinical markers such as viral load, CD4+ lymphocytes, and other more objective means of assessing adherence, such as tablet count, MEMS and pharmacy records⁷7 Hardy H, Kumar V, Doros G, Farmer E, Drainoni ML, Rybin D, Myung D, Jackson J, Backman E, Stanic A, Skolnik PR. Randomized controlled trial of a personalized cellular phone reminder system to enhance adherence to antiretroviral therapy. AIDS Patient Care STDs 2011; 25(3):153-161.^,2323 Perera AI, Thomas MG, Moore JO, Faasse K, Petrie KJ. Effect of a smartphone application incorporating personalized health-related imagery on adherence to antiretroviral therapy: a randomized clinical trial. AIDS Patient Care STDS 2014; 28(11):579-586.^,2929 Costa TM, Barbosa BJ, Gomes E, Costa DA, Sigulem D, De Fátima MH, Filho AC, Pisa IT. Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages. Int J Med Inform 2012; 81(4):257-269.^,3636 Beer L, Skarbinski J. Adherence to antiretroviral therapy among HIV-infected adults in the United States. AIDS Educ. Prev 2014; 26(6):521-537..

Regarding the quality of the clinical trials analyzed, four reached the maximum score in Jadad’s Scale¹⁵15 Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin. Trials 1996; 17(1):1-12., indicating that a significant number of the studies were double-blind. It was evidenced that double-blind produces more consistent results by reducing selection biases and ensuring the reliability of the information collected¹⁵15 Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin. Trials 1996; 17(1):1-12..

Conclusion

The use of the telephone as a tool to support the care of adults with HIV/AIDS was effective in improving adherence to ART and the relationship between professionals and patients. The phone was used in different ways and involved the use of applications on the device with internet access, text messaging, and telephone calls. Text messages stood out for their low cost. The limitations associated with using the telephone were accessibility and training for the use of electronic devices.

Future experimental studies with telephone use should consider the comparison of intervention methods, the association of methods of measurement and comparison between objective methods, factorial clinical trials (multiple interventions) and comparison between the frequency of applied interventions. Also, one should consider and develop more research that seeks to identify user perception of the most efficient interventions.

The limitation of the review was the impossibility of carrying out meta-analysis from the selected studies due to the heterogeneity of the clinical trials concerning the different measures of adherence to ART, the different variable endpoint and the lack of statistical data, which impaired the calculation of the summary measures.

References

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