How are interventions implemented to improve global HIV prevention and treatment? A systematic review of published implementation strategies used in low- and middle-income countries

BACKGROUND: Understanding the characteristics, breadth, and overall landscape of current HIV implementation research can help identify critical gaps and inform future investigation and service delivery. The LIVE project (Living Database of HIV Implementation Science) conducted a systematic review to describe the features of implementation strategies included in published studies of HIV interventions in low- and middle-income countries (LMICs).
METHODS: Embase and Medline databases were searched for HIV studies published after 2004. Abstract and full texts were screened for studies of any design, in any LMIC population, that described intervention implementation and reported at least one HIV cascade outcome. Strategies were extracted per the Proctor et al. framework (e.g., actor, action, action target). Waltz et al. clustered strategies were used to characterize strategies across the HIV care cascade.
RESULTS: Between 1-Jan-2014 and 3-Feb-2022, 42,595 abstracts were identified, 1,531 (3.6%) were included for full-text review, and 418 (27.3%) met inclusion criteria. Included studies were from Africa (82.5%), Asia-Pacific (11.5%), the Americas (4.8%), and Europe (1.2%). We identified 3,253 total strategies (Figure 1, median 6 per study, range 1-44), representing 409 unique actor-action-action target combinations. Strategies targeted HIV prevention (5.3%), testing (29.5%), and treatment (65.2%). The most used strategies involved members of the healthcare workforce engaging patients (e.g. providing education on HIV treatment or prevention, providing routine HIV counseling; 45.5%) and adapting and tailoring interventions to the implementation context (12.8%). Many strategies also involved study teams engaging patients (9.1%) or training providers and other stakeholders (6.3%). Evaluative/iterative and financial strategies were less commonly applied.

CONCLUSIONS: Use of healthcare workforce to engage patients has been commonplace in published evaluations of HIV services. Few studies reported providing technical assistance, changing financial systems, conducting service evaluation, or involving individuals affected by HIV and policymakers in the implementation process. There is a need to evaluate other promising strategies for implementation effectiveness.

S. Lujintanon * (1,2), C.G. Kemp (1,3), I. Eshun-Wilson (4), L. Beres (1,3), S. Schwartz (1,2), S. Baral (1,2), R. Thompson (2), N. Le Tourneau (4), B. Fox (4), E.H. Geng (4)
(1) Johns Hopkins Bloomberg School of Public Health, Center for Implementation Research and Practice, Baltimore, United States, (2) Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, United States, (3) Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, United States, (4) Washington University School of Medicine in St. Louis, Division of Infectious Diseases, St. Louis, United States