How Do Psychosocial Interventions for Adolescents and Young People Living With HIV Improve Adherence and Viral Load? A Realist Review



      Psychosocial interventions have the potential to support adolescents and young people living with HIV (AYPLHIV) to achieve better HIV outcomes. However, more evidence is needed to understand which interventions are most effective, and the mechanisms driving how they work in practice.


      We used realist methodologies to generate statements based on evidence from intervention studies and linked evidence included in a systematic review of psychosocial interventions for AYPLHIV. Key data were extracted from available sources to generate cases, including context-mechanism-outcome pathways. Higher level themes were refined iteratively to create a mid-range theory of how these interventions may work.


      From 26 resulting cases, 8 statements were crafted, grouped into 3 overarching categories, to describe how these interventions worked. Interventions were overall found to set off mechanisms to improve adherence when (1) responding to individual-level factors to support AYPLHIV (via incorporating agency and empowerment, personalized and/or contextualized approaches, and self-care skills); (2) tailoring delivery strategies to address specific needs (via diverse strategies, longer duration, and digital delivery); and (3) providing supportive resources (via peer and broader support, and structural support and integration into existing services).


      A collection of diverse mechanisms may individually or collectively drive improved outcomes for AYPLHIV engaged in psychosocial interventions. Recommendations for integrating our findings into practice are discussed.


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        • Spaan P.
        • van Luenen S.
        • Garnefski N.
        • Kraaij V.
        Psychosocial interventions enhance HIV medication adherence: A systematic review and meta-analysis.
        J Health Psychol. 2020; 25: 1326-1340
        • Whiteley L.B.
        • Olsen E.M.
        • Haubrick K.K.
        • et al.
        A review of interventions to enhance HIV medication adherence.
        Curr HIV/AIDS Rep. 2021; 18: 443-457
        • Ma Q.
        • Tso L.S.
        • Rich Z.C.
        • et al.
        Barriers and facilitators of interventions for improving antiretroviral therapy adherence: A systematic review of global qualitative evidence.
        J Int AIDS Soc. 2016; 19: 21166
        • Gonzalez M.L.
        • Butler A.S.
        • England M.J.
        Psychosocial interventions for mental and substance use disorders: A framework for establishing evidence-based standards.
        National Academies Press, Washington, DC2015
        • World Health Organization
        Guidelines on mental health promotive and preventive interventions for adolescents: Helping adolescents thrive.
        World Health Organization, Geneva2020
        • Bova C.
        • Burwick T.N.
        • Quinones M.
        Improving women's adjustment to HIV infection: Results of the positive life skills Workshop Project.
        J Assoc Nurses AIDS Care. 2008; 19: 58-65
        • Jones D.L.
        • Ishii M.
        • LaPerriere A.
        • et al.
        Influencing medication adherence among women with AIDS.
        AIDS Care. 2003; 15: 463-474
        • van Luenen S.
        • Garnefski N.
        • Spinhoven P.
        • et al.
        The benefits of psychosocial interventions for mental health in people living with HIV: A systematic review and meta-analysis.
        AIDS Behav. 2018; 22: 9-42
        • Brennan-Ing M.
        • Seidel L.
        • Geddes L.
        • et al.
        Adapting a telephone support intervention to address depression in older adults with HIV.
        J HIV/AIDS Social Serv. 2017; 16: 335-350
        • The Healthy Living Project Team
        Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: The healthy living Project randomized controlled study.
        JAIDS J Acquired Immune Deficiency Syndromes. 2007; 44: 213-221
        • Day S.
        • Kapogiannis B.G.
        • Shah S.K.
        • et al.
        Adolescent participation in HIV research: Consortium experience in low and middle-income countries and scoping review.
        Lancet HIV. 2020; 7: e844-e852
        • Mark D.
        • Geng E.
        • Vorkoper S.
        • et al.
        Making implementation science work for children and adolescents living with HIV.
        J Acquir Immune Defic Syndr. 2018; 78: S58-S62
        • Aarons G.A.
        • Reeder K.
        • Sam-Agudu N.A.
        • et al.
        Implementation determinants and mechanisms for the prevention and treatment of adolescent HIV in sub-Saharan Africa: Concept mapping of the NIH Fogarty International Center Adolescent HIV Implementation Science Alliance (AHISA) Initiative.
        Implement Sci Commun. 2021; 2: 53
        • Harrison A.
        • Newell M.-L.
        • Imrie J.
        • Hoddinott G.
        HIV prevention for South African youth: Which interventions work? A systematic review of current evidence.
        BMC Public Health. 2010; 10: 102
        • Ridgeway K.
        • Dulli L.S.
        • Murray K.R.
        • et al.
        Interventions to improve antiretroviral therapy adherence among adolescents in low- and middle-income countries: A systematic review of the literature.
        PLOS ONE. 2018; 13: e0189770
        • Laurenzi C.A.
        • du Toit S.
        • Ameyan W.
        • et al.
        Psychosocial interventions for improving engagement in care and health and behavioural outcomes for adolescents and young people living with HIV: A systematic review and meta-analysis.
        J Int AIDS Soc. 2021; 24: e25741
        • World Health Organization
        Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: Recommendations for a public health approach.
        World Health Organization, Geneva2021 (Report No.: 9240031596)
        • UNICEF
        Adolescent HIV prevention data 2020.
        (Available at:)
        • Enane L.A.
        • Vreeman R.C.
        • Foster C.
        Retention and adherence: Global challenges for the long-term care of adolescents and young adults living with HIV.
        Curr Opin HIV AIDS. 2018; 13: 212-219
        • Pawson R.
        • Greenhalgh T.
        • Harvey G.
        • Walshe K.
        Realist synthesis: An introduction.
        ESRC Research Methods Programme, University of Manchester, Manchester2004
        • Pawson R.
        • Greenhalgh T.
        • Harvey G.
        • Walshe K.
        Realist review-a new method of systematic review designed for complex policy interventions.
        J Health Serv Res Policy. 2005; 10: 21-34
        • World Health Organization
        Updated recommendations on service delivery for the treatment and care of people living with HIV.
        World Health Organization, Geneva2021
        • Wong G.
        • Greenhalgh T.
        • Pawson R.
        Internet-based medical education: A realist review of what works, for whom and in what circumstances.
        BMC Med Education. 2010; 10: 12
        • Dulli L.
        • Ridgeway K.
        • Packer C.
        • et al.
        An online support group intervention for adolescents living with HIV in Nigeria: A pre-post test study.
        JMIR Public Health Surveill. 2018; 4: e12397
        • Belzer M.E.
        • Naar-King S.
        • Olson J.
        • et al.
        The use of cell phone support for non-adherent HIV-infected youth and young adults: An initial randomized and controlled intervention trial.
        AIDS Behav. 2014; 18: 686-696
        • Sayegh C.S.
        • MacDonell K.K.
        • Clark L.F.
        • et al.
        The impact of cell phone support on psychosocial outcomes for youth living with HIV Nonadherent to antiretroviral therapy.
        AIDS Behav. 2018; 22: 3357-3362
        • Bermudez L.G.
        • Ssewamala F.M.
        • Neilands T.B.
        • et al.
        Does economic strengthening improve viral suppression among adolescents living with HIV? Results from a cluster randomized trial in Uganda.
        AIDS Behav. 2018; 22: 3763-3772
        • Ssewamala F.M.
        • Dvalishvili D.
        • Mellins C.A.
        • et al.
        The long-term effects of a family based economic empowerment intervention (Suubi+Adherence) on suppression of HIV viral loads among adolescents living with HIV in southern Uganda: Findings from 5-year cluster randomized trial.
        PLoS One. 2020; 15: e0228370
        • Berrien V.M.
        • Salazar J.C.
        • Reynolds E.
        • McKay K.
        Adherence to antiretroviral therapy in HIV-infected pediatric patients improves with home-based intensive nursing intervention.
        AIDS Patient Care STDS. 2004; 18: 355-363
        • Bhana A.
        • Mellins C.A.
        • Petersen I.
        • et al.
        The VUKA family program: Piloting a family-based psychosocial intervention to promote health and mental health among HIV infected early adolescents in South Africa.
        AIDS care. 2014; 26: 1-11
        • Brown L.K.
        • Kennard B.D.
        • Emslie G.J.
        • et al.
        Effective treatment of depressive disorders in medical clinics for adolescents and young adults living with HIV: A controlled trial.
        J Acquir Immune Defic Syndr. 2016; 71: 38-46
        • Chen X.
        • Murphy D.A.
        • Naar-King S.
        • Parsons J.T.
        A Clinic-based motivational intervention improves condom use among subgroups of youth living with HIV.
        J Adol Health. 2011; 49: 193-198
        • Naar-King S.
        • Parsons J.T.
        • Murphy D.A.
        • et al.
        Improving health outcomes for youth living with the human immunodeficiency virus: A multisite randomized trial of a motivational intervention targeting multiple risk behaviors.
        Arch Pediatr Adolesc Med. 2009; 163: 1092-1098
        • Christodoulou J.
        • Abdalian S.E.
        • Jones A.S.K.
        • et al.
        Crystal clear with active visualization: Understanding medication adherence among youth living with HIV.
        AIDS Behav. 2020; 24: 1207-1211
        • Denison J.A.
        • Burke V.M.
        • Miti S.
        • et al.
        Project YES! Youth engaging for success: A randomized controlled trial assessing the impact of a clinic-based peer mentoring program on viral suppression, adherence and internalized stigma among HIV-positive youth (15-24 years) in Ndola, Zambia.
        PLoS One. 2020; 15: e0230703
        • Dulli L.
        • Ridgeway K.
        • Packer C.
        • et al.
        A social Media-based support group for youth living with HIV in Nigeria (SMART Connections): Randomized controlled trial.
        J Med Internet Res. 2020; 22: e18343
        • Garofalo R.
        • Kuhns L.M.
        • Hotton A.
        • et al.
        A randomized controlled trial of personalized Text message reminders to promote medication adherence among HIV-positive adolescents and young adults.
        AIDS Behav. 2016; 20: 1049-1059
        • Mimiaga M.J.
        • Bogart L.M.
        • Thurston I.B.
        • et al.
        Positive strategies to enhance problem-solving skills (STEPS): A pilot randomized, controlled trial of a Multicomponent, technology-Enhanced, Customizable antiretroviral adherence intervention for HIV-infected adolescents and young adults.
        AIDS Patient Care STDS. 2019; 33: 21-24
        • Kaihin R.
        • Kasatpibal N.
        • Chitreechuer J.
        • Grimes R.M.
        Effect of an empowerment intervention on antiretroviral Drug adherence in Thai youth.
        Behav Med. 2015; 41: 186-194
        • Linnemayr S.
        • Huang H.
        • Luoto J.
        • et al.
        Text messaging for improving antiretroviral therapy adherence: No effects after 1 Year in a randomized controlled trial among adolescents and young adults.
        Am J Public Health. 2017; 107: 1944-1950
        • MacCarthy S.
        • Wagner Z.
        • Mendoza-Graf A.
        • et al.
        A randomized controlled trial study of the acceptability, feasibility, and preliminary impact of SITA (SMS as an incentive to adhere): A mobile technology-based intervention informed by behavioral economics to improve ART adherence among youth in Uganda.
        BMC Infect Dis. 2020; 20: 173
        • Spratt E.S.
        • Papa C.E.
        • Mueller M.
        • et al.
        Using technology to improve adherence to HIV Medications in transitional age youth: Research reviewed, methods tried, Lessons learned.
        J Gen Med (Dover). 2017; 1: 1002
        • Hosek S.G.
        • Harper G.W.
        • Lemos D.
        • et al.
        Project ACCEPT: Evaluation of a group-based intervention to improve engagement in care for youth newly diagnosed with HIV.
        AIDS Behav. 2018; 22: 2650-2661
        • Naar-King S.
        • Outlaw A.Y.
        • Sarr M.
        • et al.
        Motivational enhancement System for adherence (MESA): Pilot randomized trial of a brief computer-delivered prevention intervention for youth initiating antiretroviral treatment.
        J Pediatr Psychol. 2013; 38: 638-648
        • Naar-King S.
        • Wright K.
        • Parsons J.T.
        • et al.
        Healthy choices: Motivational enhancement therapy for health risk behaviors in HIV-positive youth.
        AIDS Educ Prev. 2006; 18: 1-11
        • Naar-King S.
        • Lam P.
        • Wang B.
        • et al.
        Brief report: Maintenance of effects of motivational enhancement therapy to improve risk behaviors and HIV-related health in a randomized controlled trial of youth living with HIV.
        J Pediatr Psychol. 2008; 33: 441-445
        • Nestadt D.F.
        • Saisaengjan C.
        • McKay M.M.
        • et al.
        CHAMP+ Thailand: Pilot randomized Control trial of a family-based psychosocial intervention for perinatally HIV-infected.
        Early Adolescents. 2019; 33: 227-236
        • Rongkavilit C.
        • Naar-King S.
        • Wang B.
        • et al.
        Motivational interviewing targeting risk behaviors for youth living with HIV in Thailand.
        . 2013; 17: 2063-2074
        • Rongkavilit C.
        • Wang B.
        • Naar-King S.
        • et al.
        Motivational interviewing targeting Risky Sex in HIV-positive young Thai men who have Sex with men.
        Arch Sex Behav. 2014; 44: 329-340
        • Rotheram-Borus M.J.
        • Swendeman D.
        • Comulada W.S.
        • et al.
        Prevention for substance-using HIV-positive young people: Telephone and in-person delivery.
        J Acquir Immune Defic Syndr. 2004; 37: S68-S77
        • Mavhu W.
        • Willis N.
        • Mufuka J.
        • et al.
        Effect of a differentiated service delivery model on virological failure in adolescents with HIV in Zimbabwe (Zvandiri): A cluster-randomised controlled trial.
        Lancet. 2020; 8: e264-e275
        • Webb L.
        • Perry-Parrish C.
        • Ellen J.
        • Sibinga E.
        Mindfulness instruction for HIV-infected youth: A randomized controlled trial.
        AIDS Care. 2018; 30: 688-695
        • Whiteley L.
        • Brown L.K.
        • Mena L.
        • et al.
        Enhancing health among youth living with HIV using an iPhone game.
        AIDS care. 2018; 30: 21-33
        • Willis N.
        • Milanzi A.
        • Mawodzeke M.
        • et al.
        Effectiveness of community adolescent treatment supporters (CATS) interventions in improving linkage and retention in care, adherence to ART and psychosocial well-being: A randomised trial among adolescents living with HIV in rural Zimbabwe.
        BMC Public Health. 2019; 19: 117
        • Trickey H.
        • Thomson G.
        • Grant A.
        • et al.
        A realist review of one-to-one breastfeeding peer support experiments conducted in developed country settings.
        Matern Child Nutr. 2018; 14: e12559
        • World Health Organization
        Adolescent friendly health services for adolescents living with HIV: From theory to practice, December 2019: technical brief.
        World Health Organization, Geneva2019
      1. WHO launch 2021 guidelines with PSS 'strongly recommended' in HIV treatment and care for adolescents [press release].
        (Available at:)
        • Reisner M.S.L.
        • Mimiaga M.J.
        • Skeer M.M.
        • et al.
        A review of HIV antiretroviral adherence and intervention studies among HIV–infected youth.
        Top HIV Med. 2009; 17: 14-25
        • Crowley T.
        • van der Merwe A.
        • Skinner D.
        Adolescent HIV self-management: Lived experiences of adolescents, caregivers, and health care workers in a South African context.
        J Assoc Nurses AIDS Care. 2019; 30: e7-e19
        • Ssewamala F.M.
        • Wang J.S.-H.
        • Neilands T.B.
        • et al.
        Cost-effectiveness of a savings-Led economic empowerment intervention for AIDS-Affected adolescents in Uganda: Implications for scale-up in low-resource communities.
        J Adolesc Health. 2018; 62: S29-S36
        • Cluver L.D.
        • Toska E.
        • Orkin F.M.
        • et al.
        Achieving equity in HIV-treatment outcomes: Can social protection improve adolescent ART-adherence in South Africa?.
        AIDS Care. 2016; 28: 73-82
        • Galárraga O.
        • Kuo C.
        • Mtukushe B.
        • et al.
        iSAY (incentives for South African youth): Stated preferences of young people living with HIV.
        Social Sci Med. 2020; 265: 113333
        • Okonji E.F.
        • Mukumbang F.C.
        • Orth Z.
        • et al.
        Psychosocial support interventions for improved adherence and retention in ART care for young people living with HIV (10-24 years): A scoping review.
        BMC Public Health. 2020; 20: 1841
        • Casale M.
        • Carlqvist A.
        • Cluver L.
        Recent interventions to improve retention in HIV care and adherence to antiretroviral treatment among adolescents and youth: A systematic review.
        AIDS Patient Care STDs. 2019; 33: 237-252
        • Slogrove A.L.
        • Sohn A.H.
        The global epidemiology of adolescents living with HIV: Time for more granular data to improve adolescent health outcomes.
        Curr Opin HIV AIDS. 2018; 13: 170-178
        • Mark D.
        • Armstrong A.
        • Andrade C.
        • et al.
        HIV treatment and care services for adolescents: A situational analysis of 218 facilities in 23 sub-Saharan African countries.
        J Int AIDS Soc. 2017; 20: 21591
        • Wogrin C.
        • Willis N.
        • Mutsinze A.
        • et al.
        It helps to talk: A guiding framework (TRUST) for peer support in delivering mental health care for adolescents living with HIV.
        PloS One. 2021; 16: e0248018
        • Sam-Agudu N.A.
        • Folayan M.O.
        • Haire B.G.
        Program implementation gaps and ethical issues in the prevention of HIV infection among infants, children, and adolescents in sub-Saharan Africa.
        Pediatr Res. 2020; 87: 406-413
        • World Health Organization, UNICEF
        Helping adolescents thrive toolkit: Strategies to promote and protect adolescent mental health and reduce self-harm and other risk behaviours.
        World Health Organization/UNICEF, Geneva2021
        • World Health Organization
        HIV strategic information: Accelerating progress on HIV testing and treatment for children and adolescents through improved strategic information.
        World Health Organization, Geneva2020 (Report No.: 9240007741)
        • Okumu M.
        • Nyoni T.
        • Byansi W.
        Alleviating psychological distress and promoting mental wellbeing among adolescents living with HIV in sub-Saharan Africa, during and after COVID-19.
        Glob Public Health. 2021; 16: 964-973