You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Improved retention associated with community-based accompaniment for antiretroviral therapy delivery in rural Rwanda.
Abstract 1:
BACKGROUND Minimizing death and ensuring high retention and good adherence remain ongoing challenges for human immunodeficiency virus ( HIV ) treatment programs . We examined whether the addition of community-based accompaniment ( characterized by daily home visits from a community health worker , directly observed treatment , nutritional support , transportation stipends , and other support as needed ) to the Rw and a national model for antiretroviral therapy ( ART ) delivery would improve retention in care , viral load suppression , and change in CD4 count , relative to the national model alone . METHODS We conducted a prospect i ve observational cohort study among 610 HIV-infected adults initiating ART in 1 of 2 programs in rural Rw and a. Psychosocial and clinical characteristics were recorded at ART initiation . Death , treatment retention , and plasma viral load were assessed at 1 year . CD4 count was evaluated at 6-month intervals . Multivariable regression models were used to adjust for baseline differences between the 2 population s. RESULTS Eighty-five percent and 79 % of participants in the community-based and clinic-based programs , respectively , were retained with viral load suppression at 1 year . After adjusting for CD4 count , depression , physical health quality of life , and food insecurity , community-based accompaniment was protective against death or loss to follow-up during the first year of ART ( hazard ratio , 0.17 ; 95 % confidence interval [ CI ] , .09-.35 ; P < .0001 ) . In a second multivariable analysis , individuals receiving accompaniment were more likely to be retained with a suppressed viral load at 1 year ( risk ratio : 1.15 ; 95 % CI , 1.03 - 1.27 ; P = .01 ) . CONCLUSIONS These findings indicate that community-based accompaniment is effective in improving retention , when added to a clinic-based program with fewer patient support mechanisms


Title 2:
Improving antiretroviral therapy adherence in resource‐limited settings at scale: a discussion of interventions and recommendations
Abstract 2:
Abstract Introduction : Successful population ‐level antiretroviral therapy ( ART ) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale‐up and , ultimately , the end of AIDS . Although many people living with HIV are adhering well , others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy . Despite the importance of ART adherence , supportive interventions have generally not been implemented at scale . The objective of this review is to summarize the recommendations of clinical , research , and public health experts for scalable ART adherence interventions in re source ‐limited setting s. Methods : In July 2015 , the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in re source ‐limited setting s. This article summarizes that discussion with recent up date s. It is not a systematic review , but rather provides practical considerations for programme implementation based on evidence from individual studies , systematic review s , meta‐analyses , and the World Health Organization Consoli date d Guidelines for HIV , which include evidence from r and omized controlled trials in low‐ and middle‐income countries . Interventions are categorized broadly as education and counselling ; information and communication technology‐enhanced solutions ; healthcare delivery restructuring ; and economic incentives and social protection interventions . Each category is discussed , including descriptions of interventions , current evidence for effectiveness , and what appears promising for the near future . Approaches to intervention implementation and impact assessment are then described . Results and discussion : The evidence base is promising for currently available , effective , and scalable ART adherence interventions for re source ‐limited setting s. Numerous interventions build on existing health care infrastructure and leverage available re sources . Those most widely studied and implemented to date involve peer counselling , adherence clubs , and short message service ( SMS ) . Many additional interventions could have an important impact on ART adherence with further development , including st and ardized counselling through multi‐media technology , electronic dose monitoring , de central ized and differentiated models of care , and livelihood interventions . Optimal targeting and tailoring of interventions will require improved adherence measurement . Conclusions : The opportunity exists today to address and resolve many of the challenges to effective ART adherence , so that they do not limit the potential of ART to help bring about the end of AIDS


Title 3:
Improving antiretroviral therapy scale-up and effectiveness through service integration and decentralization
Abstract 3:
Background : Current service delivery systems do not reach all people in need of antiretroviral therapy ( ART ) . In order to inform the operational and service delivery section of the WHO 2013 consoli date d antiretroviral guidelines , our objective was to summarize systematic review s on integrating ART delivery into maternal , newborn , and child health ( MNCH ) care setting s in countries with generalized epidemics , tuberculosis ( TB ) treatment setting s in which the burden of HIV and TB is high , and setting s providing opiate substitution therapy ( OST ) ; and de central izing ART into primary health facilities and communities . Design : A summary of systematic review s. Methods : The review ers search ed PubMed , Embase , PsycINFO , Web of Science , CENTRAL , and the WHO Index Medicus data bases . R and omized controlled trials and observational cohort studies were included if they compared ART coverage , retention in HIV care , and /or mortality in MNCH , TB , or OST facilities providing ART with MNCH , TB , or OST facilities providing ART services separately ; or primary health facilities or communities providing ART with hospitals providing ART . Results : The review ers identified 28 studies on integration and de central ization . Antiretroviral therapy integration into MNCH facilities improved ART coverage ( relative risk [ RR ] 1.37 , 95 % confidence interval [ CI ] 1.05–1.79 ) and led to comparable retention in care . ART integration into TB treatment setting s improved ART coverage ( RR 1.83 , 95 % CI 1.48–2.23 ) and led to a nonsignificant reduction in mortality ( RR 0.55 , 95 % CI 0.29–1.05 ) . The limited data on ART integration into OST services indicated comparable rates of ART coverage , retention , and mortality . Partial de central ization into primary health facilities improved retention ( RR 1.05 , 95 % CI 1.01–1.09 ) and reduced mortality ( RR 0.34 , 95 % CI 0.13–0.87 ) . Full de central ization improved retention ( RR 1.12 , 95 % CI 1.08–1.17 ) and led to comparable mortality . Community-based ART led to comparable rates of retention and mortality . Conclusion : Integrating ART into MNCH , TB , and OST services was often associated with improvements in ART coverage , and de central ization of ART into primary health facilities and communities was often associated with improved retention . Neither integration nor de central ization was associated with adverse outcomes . These data contributed to recommendations in the WHO 2013 consoli date d antiretroviral guidelines to integrate ART delivery into MNCH , TB , and OST services and to de central ize ART


Title 4:
Determinants of non‐compliance with Antiretroviral Therapy among adults living with HIV/AIDS: A Systematic Review
Abstract 4:
Background Non‐compliance with Antiretroviral Therapy is a major public health concern and further challenged by interaction of various social and clinical obstacles . So ; near perfect pill taking is desirable in order to maximise its benefits . Objectives To systematic ally search , appraise and synthesis e the best available evidence on determinants of non‐compliance with Antiretroviral Therapy among adults living with HIV/AIDS and provide direction to future how to increase compliance with Antiretroviral Therapy . Inclusion criteria Types of participants The systematic review considered studies with 18 years and above year old adults living with HIV/AIDS . Focus of the review Determinants of non‐compliance with Antiretroviral Therapy among adults living with HIV/AIDS . Types of studies Quantitative study design s were considered for inclusion . Types of outcomes Socio‐economic , Health service , Psychosocial and behavioural and Clinical related outcomes . Search strategy English language articles published between January1997 and December 2011 were sought across major data bases . Method ological quality Method ological quality was assessed using Joanna Briggs Institute Meta Analysis of Statistical Assessment and Review Instrument critical appraisal tools . Data collection Data were extracted from papers included in the review by using a st and ardized data extraction tool . Data synthesis Meta‐ analysis was conducted using fixed and r and om effects model with mantel Haenszel method using Revman5 software . Heterogeneity between the studies was assessed using & khgr;2 test at a p‐value of < 0.05 . Summary statistics were expressed as adjusted odds ratio or adjusted risk ratio with 95 % confidence intervals at a p‐value of < 0.05 . Results Nine studies ( seven cross‐sectional , one cohort study and one case‐control study ) were included in the review . Results from meta analysis showed that white race adults living with HIV/AIDS  were 1.38 times more likely to non‐comply with Antiretroviral Therapy when compared with black adults living with HIV/ AIDS ( Adjusted Relative Risk=1.38 ; 95%CI=1.21 , 1.58 , p value<0.00001 ) .  Non‐depressed adults living with HIV/AIDS  were 1.77 times more likely to non‐comply with Antiretroviral Therapy when compared with depressed adults living with HIV/AIDS ( Adjusted Odds ratio = 1.77 ; 95%CI=1.17 , 2.69 , p value=0.007 ) . Substance non‐user adults living with HIV/ AIDS were 2.04 times more likely to non‐comply with Antiretroviral Therapy when compared with substance user adults living with HIV/ AIDS ( Adjusted Relative Risk = 2.04 ; 95%CI=1.51 , 2.74 , p value=<0.00001 ) . Adults living with HIV/ AIDS with baseline CD4 count ≥200cells/ml were 1.8 times more likely to non‐comply with Antiretroviral Therapy when compared with adults livings with HIV/ AIDS with baseline CD4 count ≥200cells/ml ( Adjusted Odds ratio=1.84 ; 95%CI=1.08 , 3.15 , p value=0.03 ) . Conclusion We found the base line CD4 count ≥200cells/ml , not being depressed ; not using substances and being white in race were associated with non‐compliance with Antiretroviral Therapy . Implication s for practice Behavioural change via counselling should be encouraged as a way to increase compliance . Reminders to take mediations regularly , on time , offering encouragement to keep going , helping to keep clinic appointments and providing emotional support for adults living with HIV/AIDS is important . Implication s for research Further research utilizing more robust experimental methods would help to further explore the findings of this review
Conclusion Although we could distill various components of the Intervention- Context -Actor-Mechanism- Outcome analytic tool from different studies exploring group-based programmes , we could not , however , identify a salient programme theory based on the Intervention- Context -Actor-Mechanism- Outcome heuristic analysis .