Implementation considerations

• Counselling and education have been widely integrated into national programmes, although barriers include limited training, compensation for lay workers and risks of unintended HIV disclosure. Peer and community support groups are effective and should be supported.
• To maximize impact, adherence support strategies should be directed towards individuals with the greatest risk of suboptimal adherence.
• Consideration should be given to combining or sequencing adherence interventions in terms of duration and intensity to suit the needs and preferences of the individual. Adherence should be reassessed during clinical appointments.
• The initial months following diagnosis and treatment initiation are especially critical, since disengagement from care is more likely during this period; early and targeted support during this period can improve longterm treatment outcomes.
• Preferred locations for adherence support (facility, community and telehealth) may vary by context and client preference; in some settings, clinic-based support is favoured because of lower stigma and easier access.
• Adherence support systems can be leveraged across comorbid conditions, including diabetes, hypertension and mental health, to improve the efficiency and continuity of care.
• Reminders and supporter-based strategies must be designed to avoid inadvertent HIV disclosure by using optin communication, neutral wording and clear consent.
• Self-care and self-management should be promoted using simplified tools, education and empowerment strategies, especially in settings with limited health system capacity.
• Explaining the goal of U=U (undetectable = untransmissible) is key to supporting ART adherence. Simple, low-cost approaches for measuring adherence
• Pharmacy refill records provide information on when people pick up their antiretroviral drugs.
• Pill counts may help to assess adherence but may not be feasible in routine care settings. Pill count has been found to perform better when combined with self-reported adherence.
• A key value of all these approaches is that they encourage discussions about adherence with people receiving ART.