Implementation of antiretroviral therapy adherence interventions: a realist synthesis of evidence.
OBJECTIVE
This paper is a report of a synthesis of evidence on implementation of interventions to improve adherence to antiretroviral therapy.


BACKGROUND
Evidence on efficacy must be supplemented with evidence on how interventions were implemented in practice and on how that implementation varied across populations and settings.


METHODS
Sixty-one reports were reviewed of studies conducted in the United States of America in the period 2001 to December 2008. Fifty-two reports were included in the final analysis: 37 reporting the effects of interventions and 15 reporting intervention feasibility, acceptability, or fidelity.


METHODS
An adaptation of Pawson's realist synthesis method was used, whereby a provisional explanatory model and associated list of propositions are developed from an initial review of literature. This model is successively refined to the point at which it best explains empirical findings from the reports reviewed.


RESULTS
The final explanatory model suggests that individuals with HIV will be more likely to enroll in interventions that protect their confidentiality, to attend when scheduling is responsive to their needs, and both to attend and continue with an intervention when they develop a strong, one-to-one relationship with the intervener. Participants who have limited prior experience with antiretroviral therapy will be more likely to continue with an intervention than those who are more experienced. Dropout rates are likely to be higher when interventions are integrated into existing delivery systems than when offered as stand-alone interventions.


CONCLUSIONS
The explanatory model developed in this study is intended to provide guidance to clinicians and researchers on the points in the implementation chain that require strengthening.
Leeman
Jennifer
J
School of Nursing, University of North Carolina, Chapel Hill, USA. jleeman@email.unc.edu
Chang
Yun Kyung
YK
Lee
Eun Jeong
EJ
Voils
Corrine I
CI
Crandell
Jamie
J
Sandelowski
Margarete
M
D000328:Adult; D000553:Ambulatory Care; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D003219:Confidentiality; D005069:Evaluation Studies as Topic; D055317:Evidence-Based Practice; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000451:nursing; D015438:Health Behavior; D006801:Humans; D008297:Male; D055118:Medication Adherence / Q000523:psychology*; D009723:Nurse-Patient Relations; D010352:Patient Dropouts / Q000523:psychology / Q000706:statistics & numerical data*; D010353:Patient Education as Topic / Q000379:methods; D016032:Randomized Controlled Trials as Topic; D014481:United States; D016903:Drug Monitoring
D044966:Anti-Retroviral Agents