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In sensitivity analysis, our findings were robust to a modified threshold of adherence, multiple imputation for missing data and aggregate level data pooling, but not to fixed-effects meta-analyses using generalised estimation equations.
Future studies need to be conducted in larger cohorts from clinics with a range of virologic outcomes in order to determine a threshold of adherence for predicting virologic response and to evaluate whether VL testing and GART could be limited to patients with better adherence.
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If threshold levels of adherence are identified, below which therapy becomes less effective, a target can be set for intervention strategies aimed at maintaining at least a minimal level of adherence and the associated beneficial health outcomes.
In addition, Mills et al. (2006) reported pooled estimates of 77% of sub-Saharan African patients and 55% of North American patients achieving threshold measurements of adherence as defined in the included studies.
The patient sample was dichotomised based on a clinically relevant threshold of 70% adherence rate to assess the association of ICU mortality and quality of guideline adherence.
A threshold of 80% adherence measured by pharmacy refill in the previous 4 months could be used to identify patients needing enhanced adherence support and rationalise use of VL testing in resource-limited settings.
This suggests that lower A1C values may be achieved in youth with type 1 diabetes whose families attain a threshold of dietary adherence.
However, we found that in this real-world study, median treatment adherence was 83%% in all patients and 86 % in patients with two or more canagliflozin fills, which is the threshold of high adherence developed by the Pharmacy Quality Alliance and used by Centers for Medicare and Medicaid Services to evaluate Medicare plans [ 28, 29].
We recognize that any threshold for adherence is arbitrary.
The recommended target threshold for adherence in many programs is 95%.
Sensitivity analyses will be conducted with regard to thresholds for adherence, methods of handling missing data and fixed-effects meta-analysis.
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