AIDS and Behavior

, Volume 21, Issue 6, pp 1755–1767 | Cite as

Barriers and Facilitators to Interventions Improving Retention in HIV Care: A Qualitative Evidence Meta-Synthesis

  • Brian J. HallEmail author
  • Ka-Lon Sou
  • Rachel Beanland
  • Mellanye Lacky
  • Lai Sze Tso
  • Qingyan Ma
  • Meg Doherty
  • Joseph D. Tucker
Original Paper


Retention in HIV care is vital to the HIV care continuum. The current review aimed to synthesize qualitative research to identify facilitators and barriers to HIV retention in care interventions. A qualitative evidence meta-synthesis utilizing thematic analysis. Prospective review registration was made in PROSPERO and review procedures adhered to PRISMA guidelines. Nineteen databases were searched to identify qualitative research conducted with individuals living with HIV and their caregivers. Quality assessment was conducted using CASP and the certainty of the evidence was evaluated using CERQual. A total of 4419 citations were evaluated and 11 were included in the final meta-synthesis. Two studies were from high-income countries, 3 from middle-income countries, and 6 from low-income countries. A total of eight themes were identified as facilitators or barriers for retention in HIV care intervention: (1) Stigma and discrimination, (2) Fear of HIV status disclosure, (3) task shifting to lay health workers, (4) Human resource and institutional challenges, (5) Mobile Health (mHealth), (6) Family and friend support, (7) Intensive case management, and, (8) Relationships with caregivers. The current review suggests that task shifting interventions with lay health workers were feasible and acceptable. mHealth interventions and stigma reduction interventions appear to be promising interventions aimed at improving retention in HIV care. Future studies should focus on improving the evidence base for these interventions. Additional research is needed among women and adolescents who were under-represented in retention interventions.


HIV Retention Care continuum Meta-synthesis ARV 



We thank the WHO HIV/AIDS Department and the Guangdong Provincial Centers for Skin Diseases and STI Control for their contribution and support. We would like to thank Zhang Ye, Alice Armstrong, Nathan Ford of the WHO and Simon Lewin of the Norwegian Knowledge Centre for the Health Services for their support during concept development and manuscript review processes.

Compliance with Ethical Standards

Conflicts of interest

All authors declare they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Financial Disclosure

This project was originally commissioned and supported by the World Health Organization. Additional funding and support was provided by the Macau SAR Government and the University of Macau (SRG-000001-2014-FSS & MYRG2015-00109-FSS, PI: Hall), and (NIAID 1R01AI114310-01 and FIC 1D43TW009532-01, PI: Tucker) from the National Institutes of Health.

Supplementary material

10461_2016_1537_MOESM1_ESM.docx (15 kb)
Supplementary material 1 (DOCX 14 kb)


  1. 1.
    World Health Organization (WHO). Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach June 2013. Geneva: World Health Organization; 2013.Google Scholar
  2. 2.
    Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493–505.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Cohen MS, McCauley M, Sugarman J. Establishing HIV treatment as prevention in the HIV Prevention Trials Network 052 randomized trial: an ethical odyssey. Clin Trials. 2012;9:340–7.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    The INSIGHT START Study Group. Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. N Engl J Med. 2015;373:795–807.CrossRefPubMedCentralGoogle Scholar
  5. 5.
    The TEMPRANO ANRS. 12136 Study Group. A Trial of Early Antiretrovirals and Isoniazid Preventive Therapy in Africa. N Engl J Med. 2015;373:808–22.CrossRefGoogle Scholar
  6. 6.
    Stricker SM, Fox KA, Baggaley R, Negussie E, de Pee S, Grede N, et al. Retention in care and adherence to ART are critical elements of HIV care interventions. AIDS Behav. 2014;18(Suppl 5):S465–75.CrossRefPubMedGoogle Scholar
  7. 7.
    Giordano TP, Gifford AL, White AC Jr, Suarez-Almazor ME, Rabeneck L, Hartman C, et al. Retention in care: a challenge to survival with HIV infection. Clin Infect Dis. 2007;44:1493–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Mugavero MJ, Lin HY, Willig JH, Westfall AO, Ulett KB, Routman JS, et al. Missed Visits and Mortality among Patients Establishing Initial Outpatient HIV Treatment. Clin Infect Dis. 2009;48:248–56.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Mugavero MJ, Amico KR, Westfall AO, Crane HM, Zinski A, Willig JH, et al. Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. J Acquir Immune Defic Syndr. 2012;59:86–93.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Higa DH, Marks G, Crepaz N, Liau A, Lyles CM. Interventions to improve retention in HIV primary care: a systematic review of U.S. studies. Curr HIV/AIDS Rep. 2012;9:313–25.CrossRefPubMedGoogle Scholar
  11. 11.
    Mugavero MJ, Amico KR, Horn T, Thompson MA. The state of engagement in HIV care in the United States: from cascade to continuum to control. Clin Infect Dis. 2013;57:1164–71.CrossRefPubMedGoogle Scholar
  12. 12.
    Okeke NL, Ostermann J, Thielman NM. Enhancing linkage and retention in HIV care: a review of interventions for highly resourced and resource-poor settings. Curr HIV/AIDS Rep. 2014;11:376–92.CrossRefPubMedGoogle Scholar
  13. 13.
    Govindasamy D, Ford N, Kranzer K. Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review. AIDS. 2012;26:2059–67.CrossRefPubMedGoogle Scholar
  14. 14.
    Brookes D. Understanding qualitative research and its value in healthcare. Nurs Timesnet. 2007;103:32–3.Google Scholar
  15. 15.
    Hannes K. Chapter 4: Critical appraisal of qualitative research. In: Noyes J, Booth A, Hannes K, et al. editors. Supplementary guidance for inclusion of qualitative research in Cochrane Systematic Reviews of Interventions edition: Version 1. Cochrane Qualitative Research Methods Group; 2011.Google Scholar
  16. 16.
    Holloway I, Wheeler S. Qualitative Research in Nursing and Healthcare. New York: Wiley; 2009.Google Scholar
  17. 17.
    Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62:1006–12.CrossRefPubMedGoogle Scholar
  18. 18.
    Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12:181.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Programme CAS. Qualitative appraisal checklist for qualitative research. 2006.Google Scholar
  20. 20.
    Carlsen B, Glenton C, Pope C. Thou shalt versus thou shalt not: a meta-synthesis of GPs’ attitudes to clinical practice guidelines. Br J Gen Pract. 2007;57:971–8.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Munro SA, Lewin SA, Smith HJ, Engel ME, Fretheim A, Volmink J. Patient adherence to tuberculosis treatment: a systematic review of qualitative research. Plos Med. 2007;4:e238.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Makanjuola T, Taddese HB, Booth A. Factors associated with adherence to treatment with isoniazid for the prevention of tuberculosis amongst people living with HIV/AIDS: a systematic review of qualitative data. PLoS ONE. 2014;9:e87166.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Lewis SA, Noyes J, Hastings RP. Systematic review of epilepsy self-management interventions integrated with a synthesis of children and young people’s views and experiences. J Adv Nurs. 2015;71:478–97.CrossRefPubMedGoogle Scholar
  24. 24.
    Lewin S, Glenton C, Munthe-Kaas H, Carlsen B, Colvin CJ, Gülmezoglu M, et al. Using qualitative evidence in decision making for health and social interventions: an approach to assess confidence in findings from qualitative evidence syntheses (GRADE-CERQual). Plos Med. 2015;12:e1001895.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Booth A. Formulating answerable questions. In: Booth A, Brice A, editors. Evidence Based Practice: An Information Professional’s Handbook. London: Facet; 2004. p. 61–70.Google Scholar
  26. 26.
    Barnett-Page E, Thomas J. Methods for the synthesis of qualitative research: a critical review. BMC Med Res Methodol. 2009;9:59.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Haley DF, Golin CE, Farel CE, Wohl DA, Scheyett AM, Garrett JJ, et al. Multilevel challenges to engagement in HIV care after prison release: a theory-informed qualitative study comparing prisoners’ perspectives before and after community reentry. BMC Public Health. 2014;14:1253.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Nunn A, Eng W, Cornwall A, Beckwith C, Dickman S, Flanigan T, et al. African American patient experiences with a rapid HIV testing program in an urban public clinic. J Natl Med Assoc. 2012;104:5–13.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Quinlivan EB, Messer LC, Adimora AA, Roytburd K, Bowditch N, Parnell H, et al. Experiences with HIV testing, entry, and engagement in care by HIV-infected women of color, and the need for autonomy, competency, and relatedness. AIDS Patient Care STDs. 2013;27:408–15.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systemic reviews. BMC Med Res Methodol. 2008;8:45.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Carroll C, Booth A, Lloyd-Jones M. Should we exclude inadequately reported studies from qualitative systematic reviews? An evaluation of sensitivity analyses in two case study reviews. Qual Health Res. 2012;22:1425–34.CrossRefPubMedGoogle Scholar
  32. 32.
    Agbonyitor M. Home-based care for people living with HIV/AIDS in Plateau State, Nigeria: findings from a qualitative study. Global Public Health. 2009;4:303–12.CrossRefPubMedGoogle Scholar
  33. 33.
    Bezabhe WM, Chalmers L, Bereznicki LR, Peterson GM, Bimirew MA, Kassie DM. Barriers and facilitators of adherence to antiretroviral drug therapy and retention in care among adult HIV-positive patients: a qualitative study from Ethiopia. PLoS ONE. 2014;9:e97353.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Busza J, Besana GVR, Mapunda P, Oliveras E. Meeting the needs of adolescents living with HIV through home based care: lessons learned from Tanzania. Child Youth Serv Rev. 2014;45:137–42.CrossRefGoogle Scholar
  35. 35.
    Busza J, Dauya E, Bandason T, Mujuru H, Ferrand RA. ‘‘I don’t want financial support but verbal support’’. How do caregivers manage children’s access to and retention in HIV care in urban Zimbabwe? J Int AIDS Soc. 2014;17:18839.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Decroo T, Vandendyck M, Motsamai M, Mubanga M, Makhakhe S, Jonckheree S, et al. Community Antiretroviral Therapy Groups (CAGs) in Nazareth, Lesotho: the way forward for an effective community model for HIV care? J Acquir Immune Defic Syndr. 2011;56:e39–44.CrossRefPubMedGoogle Scholar
  37. 37.
    Mallinson RK, Rajabiun S, Coleman S. The provider role in client engagement in HIV care. AIDS Patient Care STDs. 2007;21(Suppl 1):S77–84.PubMedGoogle Scholar
  38. 38.
    Miller CM, Ketlhapile M, Rybasack-Smith H, Rosen S. Why are antiretroviral treatment patients lost to follow-up? A qualitative study from South Africa. Trop Med Int Health. 2010;15:48–54.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Rajabiun S, Mallinson RK, McCoy K, Coleman S, Drainoni ML, Rebholz C, et al. “Getting me back on track”: the role of outreach interventions in engaging and retaining people living with HIV/AIDS in medical care. AIDS Patient Care STDs. 2007;21(Suppl 1):S20–9.PubMedGoogle Scholar
  40. 40.
    Smillie K, Van Borek N, van der Kop ML, Lukhwaro A, Li N, Karanja S, et al. Mobile health for early retention in HIV care: a qualitative study in Kenya (WelTel Retain). Ajar-African J AIDS Res. 2014;13:331–8.CrossRefGoogle Scholar
  41. 41.
    Alamo S, Wabwire-Mangen F, Kenneth E, Sunday P, Laga M, Colebunders RL. Task-shifting to community health workers: evaluation of the performance of a peer-led model in an antiretroviral program in Uganda. AIDS Patient Care STDs. 2012;26:101–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Assefa Y, Lynen L, Wouters E, Rasschaert F, Peeters K, Van Damme W. How to improve patient retention in an antiretroviral treatment program in Ethiopia: a mixed-methods study. BMC Health Serv Res. 2014;14:45.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    World Bank. Information and Communications for Development: Maximizing Mobile. Washington, DC: World Bank; 2012.Google Scholar
  44. 44.
    Stangl AL, Lloyd JK, Brady LM, Holland CE, Baral S. A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come? J Int AIDS Soc. 2013;16(3Suppl 2):18734.PubMedPubMedCentralGoogle Scholar
  45. 45.
    World Health Organization (WHO). Chapter 4: Organization of Guidelines. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. Geneva: World Health Organization; 2014. p. 54–66.Google Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Brian J. Hall
    • 1
    • 2
    Email author
  • Ka-Lon Sou
    • 1
  • Rachel Beanland
    • 3
  • Mellanye Lacky
    • 4
  • Lai Sze Tso
    • 4
  • Qingyan Ma
    • 4
    • 5
  • Meg Doherty
    • 3
  • Joseph D. Tucker
    • 4
  1. 1.Global and Community Mental Health Research Group, Department of PsychologyUniversity of MacauTaipaPeople’s Republic of China
  2. 2.Department of Health, Behavior and SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  3. 3.HIV/AIDS DepartmentWorld Health OrganizationGenevaSwitzerland
  4. 4.University of North Carolina Chapel Hill Project-ChinaGuangzhouPeople’s Republic of China
  5. 5.Guangzhou Eighth People’s HospitalGuangzhouPeople’s Republic of China

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