title: Barriers and facilitators of interventions for improving antiretroviral therapy adherence: a systematic review of global qualitative evidence.
abstract: Qualitative research on antiretroviral therapy (ART) adherence interventions can provide a deeper understanding of intervention facilitators and barriers. This systematic review aims to synthesize qualitative evidence of interventions for improving ART adherence and to inform patient-centred policymaking.
  
  
  
  We searched 19 databases to identify studies presenting primary qualitative data on the experiences, attitudes and acceptability of interventions to improve ART adherence among PLHIV and treatment providers. We used thematic synthesis to synthesize qualitative evidence and the CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach to assess the confidence of review findings.
  
  
  
  Of 2982 references identified, a total of 31 studies from 17 countries were included. Twelve studies were conducted in high-income countries, 13 in middle-income countries and six in low-income countries. Study populations focused on adults living with HIV (21 studies,n=1025), children living with HIV (two studies,n=46), adolescents living with HIV (four studies,n=70) and pregnant women living with HIV (one study,n=79). Twenty-three studies examined PLHIV perspectives and 13 studies examined healthcare provider perspectives. We identified six themes related to types of interventions, including task shifting, education, mobile phone text messaging, directly observed therapy, medical professional outreach and complex interventions. We also identified five cross-cutting themes, including strengthening social relationships, ensuring confidentiality, empowerment of PLHIV, compensation and integrating religious beliefs into interventions. Our qualitative evidence suggests that strengthening PLHIV social relationships, PLHIV empowerment and developing culturally appropriate interventions may facilitate adherence interventions. Our study indicates that potential barriers are inadequate training and compensation for lay health workers and inadvertent disclosure of serostatus by participating in the intervention.
  
  
  
  Our study evaluated adherence interventions based on qualitative data from PLHIV and health providers. The study underlines the importance of incorporating social and cultural factors into the design and implementation of interventions. Further qualitative research is needed to evaluate ART adherence interventions.
authors.affiliation: University of North Carolina Project-China, Guangzhou, China.|Guangzhou Eighth People's Hospital, Guangzhou, China.|Center for Medical Humanities, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China.|Institute for Global Health and Infectious Diseases at UNC-Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Qingyan
authors.initials: Q
authors.lastname: Ma
authors.affiliation: University of North Carolina Project-China, Guangzhou, China.|Center for Medical Humanities, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China.
authors.forename: Lai Sze
authors.initials: LS
authors.lastname: Tso
authors.affiliation: University of North Carolina Project-China, Guangzhou, China.
authors.forename: Zachary C
authors.initials: ZC
authors.lastname: Rich
authors.affiliation: Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.|Global and Community Mental Health Research Group, Department of Psychology, University of Macau, Macau, China.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Hall
authors.affiliation: Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
authors.forename: Rachel
authors.initials: R
authors.lastname: Beanland
authors.affiliation: University of North Carolina Project-China, Guangzhou, China.|Institute for Global Health and Infectious Diseases at UNC-Chapel Hill, Chapel Hill, NC, USA.|Department of Epidemiology, School of Public Health, Shandong University, Jinan, China.
authors.forename: Haochu
authors.initials: H
authors.lastname: Li
authors.affiliation: Spencer S. Eccles Health Sciences Library, University of Utah, Salt Lake City, UT, USA.
authors.forename: Mellanye
authors.initials: M
authors.lastname: Lackey
authors.affiliation: Guangzhou Eighth People's Hospital, Guangzhou, China.
authors.forename: Fengyu
authors.initials: F
authors.lastname: Hu
authors.affiliation: Guangzhou Eighth People's Hospital, Guangzhou, China.
authors.forename: Weiping
authors.initials: W
authors.lastname: Cai
authors.affiliation: Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
authors.forename: Meg
authors.initials: M
authors.lastname: Doherty
authors.affiliation: University of North Carolina Project-China, Guangzhou, China.|Institute for Global Health and Infectious Diseases at UNC-Chapel Hill, Chapel Hill, NC, USA; jdtucker@med.unc.edu.
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Tucker
mesh_terms: D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D055118:Medication Adherence
keywords: ART adherence; health policy; intervention; qualitative research; systematic review