Evaluating the implementation process of a multicomponent intervention to improve ART adherence among adolescents and young adults living with HIV (AYAHIV)
| dc.contributor.advisor | Myer, Landon | |
| dc.contributor.author | Mogoba, Pheposadi Lekubu | |
| dc.date.accessioned | 2026-09-25T08:16:49Z | |
| dc.date.available | 2026-09-25T08:16:49Z | |
| dc.date.issued | 2026 | |
| dc.date.updated | 2026-09-25T08:12:44Z | |
| dc.description.abstract | Introduction: Despite significant progress in advancing HIV treatment outcomes, adolescents and young adults living with HIV (AYAHIV) in sub-Saharan Africa (SSA) continue to experience disproportionately poor ART adherence and viral suppression (VS) rates compared to adults. Complex multicomponent interventions have increasingly been recognised as essential for addressing the multilevel barriers to HIV care that are faced by this population. However, little is known about the factors influencing the successful implementation of such interventions in resource-limited settings. From 2021–2023, the CombinADO trial implemented a human-centred, multicomponent intervention to improve HIV outcomes among AYAHIV at 12 adolescent- and youth-friendly health facilities in Nampula, Mozambique. The trial compared an enhanced standard of care (eSOC)—usual ART care enhanced with community outreach (billboards, posters, radio shows) and clinic-based activities such as healthcare worker (HCW) training, one-stop youth-friendly services, information/motivation walls, pill containers, and HCW clinical tools—with the CombinADO package, which superadded peer support, caregiver and youth support groups, a motivational video, and mental health screening with referral to eSOC components (offered in only 6 randomly selected facilities of the 12). Clinical outcomes of the trial are reported elsewhere. This thesis focuses on the implementation process of the CombinADO intervention, applying Proctor's Implementation Outcomes Framework (IOF) to systematically assess adoption, acceptability, appropriateness, feasibility, and fidelity. The findings are then used to support the interpretation of the CombinADO trial's effectiveness outcomes to explore how intervention implementation may have contributed to the trial results. Methods: A scoping review (chapter 3) was conducted with the aim of understanding how the IOF was previously applied in ART adherence interventions for people living with HIV in SSA. Peer-reviewed literature was identified through PubMed and Google Scholar, focusing on studies conducted between 2014 and 2023 that assessed at least one IOF-defined implementation outcome. Adoption (Chapter 4) was measured pre- and post-intervention among providers using a validated scale from the Antiretroviral Treatment Access Study (ARTAS). Acceptability, appropriateness, and feasibility (chapter 5) were assessed postintervention through quantitative data from the AMHR scale at both provider and AYAHIV levels, as well as qualitative data from semi-structured provider interviews. Fidelity (chapter 6) was evaluated using implementation logs that were completed by providers during ART consultations and were further supplemented by qualitative insights regarding barriers to implementation that were collated from implementation notes and provider interviews. Results: The scoping review revealed critical gaps in the operationalisation of implementation outcomes, the use of validated measures, and the mention of implementation frameworks in guiding evaluations. Notably, acceptability and feasibility were the most frequently evaluated outcomes, while later-stage outcomes like fidelity and sustainability were underexplored (chapter 3). In analyses for the measurement of the success in implementing the CombinADO intervention, findings showed a less positive shift in provider attitudes toward adopting the intervention from pre- to post-intervention (chapter 4). Overall, acceptability, appropriateness, and feasibility were rated high. However, qualitative data highlighted significant challenges in delivering the complete intervention package due to high patient volumes, staff shortages, and issues with the intervention's form and content (chapter 5). The intervention was inconsistently implemented, with multilevel challenges experienced during implementation leading to reactive, unstructured adaptations. Assessments of fidelity suggested discrepancies between the package of components that were delivered to AYAHIV and what was initially planned, and no correlation was found between fidelity levels and viral suppression rates among AYAHIV (chapter 6). Conclusions: Overall, the results suggest that the limited effectiveness of the CombinADO intervention in improving the targeted clinic outcomes may have been related to the poor implementation and weak differentiation between the intervention and control conditions. In addition, the fidelity to delivery was further undermined by contextual challenges such as resource constraints, staff turnover, and high patient volumes. The thesis supports the importance of considering implementation outcomes alongside effectiveness outcomes, especially when evaluating complex interventions, which can facilitate a better understanding of the challenges and opportunities in the implementation process that influence the success of delivering complex interventions in resource-limited settings. Based on the key findings from this work, recommendations for future considerations in implementing complex ART adherence interventions include designing interventions with the context in mind, as such interventions will have a better chance of being delivered as expected to yield better health outcomes. Beyond addressing the needs of AYAHIV, interventions should consider fit with existing health system capabilities and be easy to tailor to fit diverse cultural, demographic, and other contextual diversities without compromising their fidelity. Future research on expanding the potential of the CombinADO intervention should focus on refining the intervention through planned adaptations and testing implementation strategies to overcome identified contextual barriers. These insights contribute to the growing body of implementation science literature, with implications for improving HIV outcomes among AYAHIV in SSA. | |
| dc.identifier.apacitation | Mogoba, P. L. (2026). <i>Evaluating the implementation process of a multicomponent intervention to improve ART adherence among adolescents and young adults living with HIV (AYAHIV)</i>. (). University of Cape Town ,Faculty of Health Sciences ,Department of Public Health and Family Medicine. Retrieved from http://hdl.handle.net/11427/43809 | en_ZA |
| dc.identifier.chicagocitation | Mogoba, Pheposadi Lekubu. <i>"Evaluating the implementation process of a multicomponent intervention to improve ART adherence among adolescents and young adults living with HIV (AYAHIV)."</i> ., University of Cape Town ,Faculty of Health Sciences ,Department of Public Health and Family Medicine, 2026. http://hdl.handle.net/11427/43809 | en_ZA |
| dc.identifier.citation | Mogoba, P.L. 2026. Evaluating the implementation process of a multicomponent intervention to improve ART adherence among adolescents and young adults living with HIV (AYAHIV). . University of Cape Town ,Faculty of Health Sciences ,Department of Public Health and Family Medicine. http://hdl.handle.net/11427/43809 | en_ZA |
| dc.identifier.ris | TY - Thesis / Dissertation AU - Mogoba, Pheposadi Lekubu AB - Introduction: Despite significant progress in advancing HIV treatment outcomes, adolescents and young adults living with HIV (AYAHIV) in sub-Saharan Africa (SSA) continue to experience disproportionately poor ART adherence and viral suppression (VS) rates compared to adults. Complex multicomponent interventions have increasingly been recognised as essential for addressing the multilevel barriers to HIV care that are faced by this population. However, little is known about the factors influencing the successful implementation of such interventions in resource-limited settings. From 2021–2023, the CombinADO trial implemented a human-centred, multicomponent intervention to improve HIV outcomes among AYAHIV at 12 adolescent- and youth-friendly health facilities in Nampula, Mozambique. The trial compared an enhanced standard of care (eSOC)—usual ART care enhanced with community outreach (billboards, posters, radio shows) and clinic-based activities such as healthcare worker (HCW) training, one-stop youth-friendly services, information/motivation walls, pill containers, and HCW clinical tools—with the CombinADO package, which superadded peer support, caregiver and youth support groups, a motivational video, and mental health screening with referral to eSOC components (offered in only 6 randomly selected facilities of the 12). Clinical outcomes of the trial are reported elsewhere. This thesis focuses on the implementation process of the CombinADO intervention, applying Proctor's Implementation Outcomes Framework (IOF) to systematically assess adoption, acceptability, appropriateness, feasibility, and fidelity. The findings are then used to support the interpretation of the CombinADO trial's effectiveness outcomes to explore how intervention implementation may have contributed to the trial results. Methods: A scoping review (chapter 3) was conducted with the aim of understanding how the IOF was previously applied in ART adherence interventions for people living with HIV in SSA. Peer-reviewed literature was identified through PubMed and Google Scholar, focusing on studies conducted between 2014 and 2023 that assessed at least one IOF-defined implementation outcome. Adoption (Chapter 4) was measured pre- and post-intervention among providers using a validated scale from the Antiretroviral Treatment Access Study (ARTAS). Acceptability, appropriateness, and feasibility (chapter 5) were assessed postintervention through quantitative data from the AMHR scale at both provider and AYAHIV levels, as well as qualitative data from semi-structured provider interviews. Fidelity (chapter 6) was evaluated using implementation logs that were completed by providers during ART consultations and were further supplemented by qualitative insights regarding barriers to implementation that were collated from implementation notes and provider interviews. Results: The scoping review revealed critical gaps in the operationalisation of implementation outcomes, the use of validated measures, and the mention of implementation frameworks in guiding evaluations. Notably, acceptability and feasibility were the most frequently evaluated outcomes, while later-stage outcomes like fidelity and sustainability were underexplored (chapter 3). In analyses for the measurement of the success in implementing the CombinADO intervention, findings showed a less positive shift in provider attitudes toward adopting the intervention from pre- to post-intervention (chapter 4). Overall, acceptability, appropriateness, and feasibility were rated high. However, qualitative data highlighted significant challenges in delivering the complete intervention package due to high patient volumes, staff shortages, and issues with the intervention's form and content (chapter 5). The intervention was inconsistently implemented, with multilevel challenges experienced during implementation leading to reactive, unstructured adaptations. Assessments of fidelity suggested discrepancies between the package of components that were delivered to AYAHIV and what was initially planned, and no correlation was found between fidelity levels and viral suppression rates among AYAHIV (chapter 6). Conclusions: Overall, the results suggest that the limited effectiveness of the CombinADO intervention in improving the targeted clinic outcomes may have been related to the poor implementation and weak differentiation between the intervention and control conditions. In addition, the fidelity to delivery was further undermined by contextual challenges such as resource constraints, staff turnover, and high patient volumes. The thesis supports the importance of considering implementation outcomes alongside effectiveness outcomes, especially when evaluating complex interventions, which can facilitate a better understanding of the challenges and opportunities in the implementation process that influence the success of delivering complex interventions in resource-limited settings. Based on the key findings from this work, recommendations for future considerations in implementing complex ART adherence interventions include designing interventions with the context in mind, as such interventions will have a better chance of being delivered as expected to yield better health outcomes. Beyond addressing the needs of AYAHIV, interventions should consider fit with existing health system capabilities and be easy to tailor to fit diverse cultural, demographic, and other contextual diversities without compromising their fidelity. Future research on expanding the potential of the CombinADO intervention should focus on refining the intervention through planned adaptations and testing implementation strategies to overcome identified contextual barriers. These insights contribute to the growing body of implementation science literature, with implications for improving HIV outcomes among AYAHIV in SSA. DA - 2026 DB - OpenUCT DP - University of Cape Town KW - adolescents KW - young adults KW - HIV LK - https://open.uct.ac.za PB - University of Cape Town PY - 2026 T1 - Evaluating the implementation process of a multicomponent intervention to improve ART adherence among adolescents and young adults living with HIV (AYAHIV) TI - Evaluating the implementation process of a multicomponent intervention to improve ART adherence among adolescents and young adults living with HIV (AYAHIV) UR - http://hdl.handle.net/11427/43809 ER - | en_ZA |
| dc.identifier.uri | http://hdl.handle.net/11427/43809 | |
| dc.identifier.vancouvercitation | Mogoba PL. Evaluating the implementation process of a multicomponent intervention to improve ART adherence among adolescents and young adults living with HIV (AYAHIV). []. University of Cape Town ,Faculty of Health Sciences ,Department of Public Health and Family Medicine, 2026 [cited yyyy month dd]. Available from: http://hdl.handle.net/11427/43809 | en_ZA |
| dc.language.iso | en | |
| dc.language.rfc3066 | eng | |
| dc.publisher.department | Department of Public Health and Family Medicine | |
| dc.publisher.faculty | Faculty of Health Sciences | |
| dc.publisher.institution | University of Cape Town | |
| dc.subject | adolescents | |
| dc.subject | young adults | |
| dc.subject | HIV | |
| dc.title | Evaluating the implementation process of a multicomponent intervention to improve ART adherence among adolescents and young adults living with HIV (AYAHIV) | |
| dc.type | Thesis / Dissertation | |
| dc.type.qualificationlevel | Doctoral | |
| dc.type.qualificationlevel | PhD |