***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Human re source limitations are a challenge to the delivery of antiretroviral therapy ( ART ) in low-re source setting s. We conducted a cluster r and omized trial to assess the effect of community-based peer health workers ( PHW ) on AIDS care of adults in Rakai , Ug and a. Methodology /Principal Findings 15 AIDS clinics were r and omized 2∶1 to receive the PHW intervention ( n = 10 ) or control ( n = 5 ) . PHW tasks included clinic and home-based provision of counseling , clinical , adherence to ART , and social support . Primary outcomes were adherence and cumulative risk of virologic failure ( > 400 copies/mL ) . Secondary outcomes were virologic failure at each 24 week time point up to 192 weeks of ART . Analysis was by intention to treat . From May 2006 to July 2008 , 1336 patients were followed . 444 ( 33 % ) of these patients were already on ART at the start of the study . No significant differences were found in lack of adherence ( < 95 % pill count adherence risk ratio [ RR ] 0.55 , 95 % confidence interval [ CI ] 0.23–1.35 ; < 100 % adherence RR 1.10 , 95 % CI 0.94–1.30 ) , cumulative risk of virologic failure ( RR 0.81 , 95 % CI 0.61–1.08 ) or in shorter-term virologic outcomes ( 24 week virologic failure RR 0.93 , 95 % CI 0.65–1.32 ; 48 week , RR 0.83 , 95 % CI 0.47–1.48 ; 72 week , RR 0.81 , 95 % CI 0.44–1.49 ) . However , virologic failure rates ≥96 weeks into ART were significantly decreased in the intervention arm compared to the control arm ( 96 week failure RR 0.50 , 95 % CI 0.31–0.81 ; 120 week , RR 0.59 , 95 % CI 0.22–1.60 ; 144 week , RR 0.39 , 95 % CI 0.16–0.95 ; 168 week , RR 0.30 , 95 % CI 0.097–0.92 ; 192 week , RR 0.067 , 95 % CI 0.0065–0.71 ) . Conclusions / Significance A PHW intervention was associated with decreased virologic failure rates occurring 96 weeks and longer into ART , but did not affect cumulative risk of virologic failure , adherence measures , or shorter-term virologic outcomes . PHWs may be an effective intervention to sustain long-term ART in low-re source setting s. Trial Registration Clinical Trials.gov Background : We prospect ively studied the impact of an adherence counselor on the outcome of patients failing antiretroviral therapy because of nonadherence . Methods : Forty-six patients , identified as chronically nonadherent were enrolled . Individual attention was provided using the information , motivation and behavioral methodology .  HIV RNA ( viral load , in copies/mL ) , CD4 count ( in cells/mm 3 ) , and body weight before and after the adherence counselor were measured . Qualitative outcome and patient satisfaction were assessed by deidentified third-party interviews . Results : Over half completed at least 1 year ; only 8 patients were lost to follow-up . Mean CD4 counts increased significantly ( P < .05 ) for completers at 6 and 12 months . Viral loads decreased between baseline and 6 months . Most clients reported subjective benefit from working with the adherence counselor . Conclusion : Although few clients showed complete virologic suppression , the value of an adherence counselor was vali date d. Longer term adherence programs should be evaluated Objective : To determine the efficacy of patient-selected treatment partners on virologic and adherence outcomes during first-line antiretroviral therapy .  Design : R and omized controlled trial . Setting and Analytical Approach : Between June 2006 and December 2007 , 499 HIV-infected adults in Jos , Nigeria , were r and omized to st and ard of care ( SOC ) or patient-selected treatment partner-assisted therapy ( TPA ) .  Each patient was followed for 48 weeks . Virologic outcomes , adherence to drug pick-up , CD4 cell counts , and mortality are reported . Results : At week 24 , undetectable viral load was achieved by 61.7 % of patients in the TPA arm versus 50.2 % of those receiving SOC [ odds ratio ( OR ) = 1.58 , 95 % CI : 1.11 to 2.26 , P < 0.05 ] . There was no significant difference at week 48 : 65.3 % versus 59.4 % for TPA and SOC , respectively ( OR = 1.28 , 95 % CI : 0.89 to 1.84 , P > 0.05 ) . The TPA group had more than 3 times the odds of at least 95 % drug pickup adherence through week 24 ( OR = 3.06 , 95 % CI : 1.89 to 4.94 , P < 0.01 ) and almost twice the odds through week 48 ( OR = 1.95 , 95 % CI : 1.29 to 2.93 , P < 0.01 ) . At week 48 , there were no significant differences in CD4 cell count increases ( t = −0.09 , df = 404 , P > 0.05 ) or mortality ( 10.6 % vs. 6.1 % ) between TPA vs. SOC , respectively . Residence-to-clinic distance was significantly associated with virologic and adherence outcomes . Conclusions : Use of patient-selected treatment partners was associated with improved drug pickup adherence and initial virologic success but had no durable effect on attaining undetectable viral load A r and omized 2-group medication adherence intervention is evaluated with HIV-infected adults ( N = 141 ) assessed at baseline , 3- , and 9-month follow-ups . Cognitive ( self-efficacy , behavioral intent ) , mental health ( depression , well-being ) , and substance use indicators were the outcome measures . In addition , a posttest-only analysis from 3 to 9 months evaluates intervention impact on antiretroviral adherence , measured through Medication Event Monitoring System and pill counts . Compared to the st and ard care group , the intervention group showed significant increases in adherence self-efficacy and behavioral intent at 3 and 9 months and marginal improvements in mental health . Although the st and ard care group had higher adherence at 3 months ( no baseline data were available prior to intervention ) , intervention group patients showed significant increases in adherence from 3 to 9 months . Although adherence levels achieved by intervention patients may not be sufficient for virological control , this is one of the first studies to provide promising results of longer term effectiveness of a behavioral adherence intervention Context Highly active antiretroviral therapy ( HAART ) improves outcomes in HIV-infected patients . When is the best time to start this therapy ? Contribution 1422 HIV-infected adults were followed for 2 to 6 years after starting HAART . Adherent patients who started treatment with lower ( 0.200 to 0.349 109 cells/L ) and higher ( 0.350 109 cells/L ) CD4 + cell counts had statistically similar mortality rates . Nonadherent patients had higher mortality rates than adherent patients , regardless of baseline CD4 + cell count of 0.200 to 0.349 109 cells/L or 0.350 109 cells/L or greater . Implication s In HIV-infected patients , adherence , rather than when therapy is initiated before a CD4 + cell count of 0.200 109 cells/L , may be the most important determinant of survival . The Editors The benefits of highly active antiretroviral therapy ( HAART ) in the management of HIV disease are well established . By suppressing plasma HIV-1 RNA , HAART decreases morbidity and mortality in HIV-infected patients ( 1 , 2 ) . However , the optimal time to initiate HAART is uncertain . As a result , expert recommendations on the optimal time to initiate antiretroviral therapy widely differ ( 3 - 6 ) . Several studies have suggested that only patients who initiated therapy when the CD4 + cell count had declined below 0.200 109 cells/L were at increased risk for disease progression , regardless of the baseline HIV RNA level ( 7 - 9 ) . In 1 of these studies , further examination with additional duration of follow-up suggested that mortality may be elevated in patients who initiated therapy after the CD4 + cell count declined below 0.350 109 cells/L ( 10 ) . In fact , a growing number of studies have suggested that delaying HAART after the CD4 + cell count declines below 0.350 109 cells/L may be unsafe ( 11 - 14 ) . However , previous studies ( 7 , 9 , 11 - 14 ) did not adjust for patient adherence . This limitation is critically important because incomplete adherence is associated with increased mortality ( 15 - 17 ) . Therefore , we sought to evaluate the effect of baseline CD4 + cell count and adherence on survival rates after the initiation of HAART . Methods The HAART Observational Medical Evaluation and Research ( HOMER ) study , conducted through the British Columbia Centre for Excellence in HIV/AIDS Drug Treatment Program , has been described in detail elsewhere ( 7 , 17 ) . Briefly , the Centre is the only free source of antiretroviral medications in British Columbia , Canada ; pharmaceutical sales suggest that less than 1 % of HIV-infected patients in this province obtain antiretroviral agents outside the program ( 18 ) . For all participants , the program maintains a complete prospect i ve profile of antiretroviral therapy . In the present study , we restricted analyses to HIV-infected men and women who had been antiretroviral naive until triple-drug antiretroviral therapy was prescribed between 1 August 1996 and 31 July 2000 and were followed through 31 March 2002 . Study participants were initially prescribed HAART regimens that included 2 nucleoside reverse transcriptase inhibitors and either a protease inhibitor or a nonnucleoside reverse transcriptase inhibitor ( the enrolling physician , in consultation with the patient , chose the regimen ) . End Points The primary end point in this analysis was time to death . Deaths occurring during the follow-up period were continuously identified from physician reports and through record linkages with the British Columbia Division of Vital Statistics . In the primary analysis , we evaluated all-cause mortality ; in subanalyses , we censored deaths from accidental causes at the time of death and classified them as nonevents ( 7 ) . Statistical Analysis KaplanMeier Analyses For the KaplanMeier analyses , we stratified patients into 5 baseline CD4 + cell count strata on the basis of previous studies and the recommendations of therapeutic guidelines : less than 0.200 , 0.200 to 0.249 , 0.250 to 0.299 , 0.300 to 0.349 , and greater than or equal to 0.350 109 cells/L ( 3 - 5 , 7 - 9 ) . We further stratified patients into adherent and nonadherent categories according to adherence to prescription refills ( 19 ) . The definition of adherence was based on the ratio of time that medication dispensed would last as a proportion of follow-up time . This calculation was restricted to each patient 's first year of therapy in order to limit the potential for reverse causation in patients who ceased antiretroviral therapy after they became too sick to take medication ( 15 , 20 ) . We have previously demonstrated that adherence defined in this way strongly predicts virologic response and mortality and that it can be used to adjust for the potentially confounding effect of treatment interruption ( 15 , 17 , 21 , 22 ) . In the primary analysis , we wanted to evaluate how moderate adherence to HAART affected survival . Therefore , to estimate the effect of moderate adherence , a priori we categorized patients as nonadherent only if they received antiretroviral medications less than 75 % of the time during the first year of therapy ( 15 , 17 ) . In a sub analysis , we estimated the risk for death from HIV disease among patients who were highly adherent to HAART .  We defined adherence more rigorously for this analysis ; patients were considered nonadherent only if they received antiretroviral medications less than 95 % of the time during the first year of therapy ( 21 , 23 ) . We also censored deaths from accidental causes at the time of death and classified them as nonevents ( 7 ) . For both analyses , we evaluated the cumulative mortality rates among the predefined baseline CD4 + cell count strata using KaplanMeier methods . Survival curves were compared by using the log-rank test . Cox Regression Analyses We were aware that additional confounding may persist if the distribution of baseline AIDS diagnoses or baseline HIV RNA levels differed between patients with various bas 
    Output:
    
Despite study diversity and limitations , evidence suggests that treatment supporters , directly observed therapy , mobile-phone text messages , diary cards , and food rations can effectively increase adherence in sub-Saharan Africa .