{"paper_id":"471d7e3f-be49-4ed6-82fd-7483ea253433","body_text":"Interventions to improve viral suppression in antiretroviral therapy patients in Africa: A Systematic Review and Meta analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Interventions to improve viral suppression in antiretroviral therapy patients in Africa: A Systematic Review and Meta analysis Lindiwe Cele, Mathildah Mpata Mokgatle, Olanrewaju This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9574334/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: A wide range of interventions have been implemented to improve viral suppression (VS) among patients on antiretroviral therapy (ART). While many of primary studies report positive effects on VS, results vary considerably across intervention type, populations and health systems context . This systematic review and meta-analysis study conducted a comprehensive search for evidence of effective interventions to improve VS among adult patients who were on antiretroviral therapy (ART) in Africa. Methods: Searches were conducted in Pubmed and EbscoHost databases (Medline and CINHAL) in July 2025. Two reviewers independently screened study titles, abstracts, and full-texts and found 15 studies which met the study inclusion criteria. Quality and risk of bias were assessed using Cochrane’s Risk of Bias 2.0 (RoB 2) and Joanna Briggs Institute (JBI) checklist. Relative risks (RR) and the 95% CIs were calculated to quantify the magnitude of the effect of interventions on viral suppression and ART adherence using STATA17. The I-squared statistic (I 2 ) was used to assess the presence of heterogeneity. Results : Behavioral support and financial support interventions were associated with statistically significant increased likelihood of improved VS, respectively, (RR=1.18, 95% CI: 1.01-1.39), and RR= 1.05 (95% CI:1.01-1.10),I 2 =47.60%. The behavioural support intervention was also significantly associated with high ART adherence (RR=1.24, 95% CI:1.06-1.44). Conclusions: These findings underscore the importance of addressing structural barriers and individual behaviors in HIV treatment programmes. Furthermore, they highlight the need for studies that will clarify the role of psychosocial and service-delivery interventions for improving VS. Systematic review registration : CRD42024532244 https://pmc.ncbi.nlm.nih.gov/articles/PMC11927478/ Infectious Diseases facilitating/improving viral suppression enhancing viral suppression reducing episodes of viral rebound resuppression Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) continue to be a major global public health concern, with 40.8 million people said to be living with HIV (PLWH), in 2024, worldwide, and 693 000 AIDS related deaths occurring in the same year (1). The African continent bears a disproportionate share of the global burden, accounting for nearly two-thirds of all PLWH (2).Although the widespread scale-up of antiretroviral therapy (ART) has resulted in substantial reduction in HIV related morbidity and mortality, the epidemic remains concentrated in specific regions and populations (3,4). South Africa has one of the highest HIV prevalence in the world with approximately 7.8 million PLWH in 2022. ART is widely available in the country, with an estimated 5 730 647 of the 7.8 million PLWH receiving treatment in the same year, 2022 (5,6,7). HIV transmission in South Africa is predominantly heterosexual, characterized by pronounced gender and age disparities. Women, particularly aged 25–29 years, experience disproportionately high HIV incidence, driven by biological susceptibility, socioeconomic inequality, gender-based violence, and structural barriers to prevention and care (8,9). Although nationwide implementation of ART has potentially transformed HIV into chronic, and manageable condition in South Africa, resulting in significant reduction in AIDS-related mortality and improvements in life expectancy, challenges of treatment adherence hinder progress in the ART program (10,11,12). Studies conducted in some parts of the country have reported suboptimal ART adherence and high default rates among participants on ART (13,14,15). Progress towards the 95-95-95 targets indicates that South Africa had 89.6% of PLWH who knew their HIV status, of which 90.7% were on ART, and 93.9% of whom were virally suppressed, in 2022 (16). The clinical and public health benefits of ART are largely dependent on achievement and maintenance of viral suppression (VS), the primary indicator of treatment effectiveness. Sustained VS reduces the risk of disease progression, emergence of drug resistance and viral transmission (17). However, VS is not consistently maintained among all patients receiving ART in routine program settings in Africa, with patient, treatment and health system related factors contributing to suboptimal outcomes (18,19,20). Persistent challenges related to adherence and viral suppression highlight the importance of behavioral, psychosocial, and structural determinants of HIV outcomes. Stigma, mental health conditions, food insecurity, limited social support, and health system constraints continue to influence adherence behaviors in high-burden settings (21,13,22). In response, a wide range of interventions including adherence support strategies, differentiated service delivery models, community-based interventions, and digital health approaches have been implemented to improve VS among patients on ART in Africa (23). While individual studies have reported results of varying degree of their effectiveness, evidence remains fragmented and heterogenous, making it difficult to draw definitive conclusions regarding which interventions are most effective across different settings and populations. This systematic review and meta-analysis (SR and MA) study synthesized available data on interventions designed to improve VS among adult patients on ART in Africa. The findings will help inform policy, program implementation, and future research. 2. Materials and Methods This systematic review and meta- analysis study was performed based on the Cochrane Handbook for Systematic Reviews of Interventions (24). We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline of 2020 (25). The study protocol was registered in PROSPERO: CRD42024532244. Protocol deviation This review was conducted in accordance with a previously published protocol (26) which restricted eligibility to studies conducted in South Africa, observational in design, and published between 2013 and 2024. The initial searches yielded no eligible studies (empty review), and this resulted in the review team broadening the eligibility criteria to enhance feasibility and ensure a meaningful synthesis of evidence. The amendment includes expansion of the geographic scope from South Africa to Africa, modification of study designs to include intervention studies, and extension of the publication year limits from 2013–2024 to 2003–2025, with the consequent adjustment of the data collection period from March 2025 to July 2025. These amendments were made following confirmation of an empty review and were not influenced by outcome data or study findings 2.1 Literature search strategy A literature search was conducted in July 2025, using Pubmed, and EbscoHost (CINHAL and Medline) electronic databases. We used the study question: (What interventions are in place for sustaining viral suppression among adult patients who are on antiretroviral therapy) to identify key concepts (interventions AND antiretroviral therapy AND viral suppression). For comprehensiveness, keywords were formulated from each of the key concepts using a combination of Medical Search Headings (MeSH) and free text terms adapted according to each database. The search terms were combined using the Boolean operators (AND, OR, NOT). We applied search filters and limits within the search interface of each database including the year of publication (2003–2025), place of publication (Africa),language restriction (English),and publication type (research articles). Search strategies were translated according to each database vocabulary and operators (Boolean, wildcard, proximity etc.),online supplementary table 1. 2.2 Eligibility criteria 2.2.1 Inclusion Criteria The studies were included if they were conducted in countries that are in the African continent, published in peer reviewed journals between the year 2003 and 2025, and if the intervention was community-based, behavioral, psychosocial, digital health, health system, or structural. 2.2.2 Exclusion Criteria The studies were excluded if they were conducted among patients who were aged younger than 18 years, and designed as systematic reviews or clinical trials, or when the outcome measure was not related to viral suppression and or ART adherence. Studies were also excluded if they were qualitative in nature, and when they lacked quantitative detail for the calculation of the effect sizes, and if there was no detailed description of the intervention. 2.2.3 Article screening and selection All retrieved studies were managed using the Rayyan software where duplicate detection and removal, including article screening were done. Two reviewers, L.C and L.N, worked independently to screen through study titles and abstracts whilst applying inclusion and exclusion criteria. Conflicting decisions between the reviewers were dealt with by comparing independent reviewer decisions, with each reviewer changing their decision as needed, through consensus. For full text screening, all included studies were filtered through the citation display. The generated results are displayed in a PRISMA flow diagram, Fig. 1 . 2.3 Data extraction Two reviewers, L.C and L.N independently used the extraction tool that was designed to collect the information from the selected studies, which includes author name (s), year of publication, study location or country, study design, number of events (intervention and control participants), total number of participants, intervention type, outcome measurements, viral load threshold, ART duration, and the point estimates with the corresponding 95% confidence intervals (95% CI). 2.4 Quality assessment We used the Cochrane criteria for the systematic assessment of risk of bias in randomized controlled trials (RCTs) and Quasi experiment/ intervention studies, the Cochrane Risk of Bias tool (RoB 2), and Joanna Briggs Institute (JBI) checklist for cohort studies (27, 28). Each study was independently assessed across predefined domains, with disagreements resolved through discussion. Based on the risk of bias assessment, the overall quality of studies was graded as low, medium or high risk, supplementary tables 2 and 3. 2.5 Data synthesis and analysis The extracted data were captured onto Microsoft Excel spreadsheet, and these were analyzed on Stata version 17 using the Random Effects Model Maximum Likelihood method. The meta-analysis included studies that reported the number of events and the total number of participants by control and intervention arm for VS and ART adherence outcomes. For VS, threshold values varied; one was study specific, using 40copies/ml (29), with the other 10 being context specific based on the country and/or WHO definition of VS at the time of the study (50 copies/ ml, 200 copies/ ml, 400 copies/ml, and 1000 copies/ml). The high ART adherence ranged between 80% and 100%. The duration of the measured outcomes (viral suppression and ART adherence) ranged between 6 and 24 months. We conducted subgroup analysis using the intervention type groupings (behavioral support (BSI), financial support (FSI), psychosocial support (PSI), and specialized dispensing (SDI)). Risk ratios (RR) were calculated to determine the effectiveness of the interventions including the 95% confidence intervals (95% CIs), and the weight proportion that each study contributed, and these were displayed on forest plots. We used Cochran’s Q and I 2 to assess heterogeneity of the studies; I 2 < 50% considered low, 50%-70% considered moderate and > 75% considered high heterogeneity (30). Publication bias was assessed using the Funnel plots. To explore the impact of deviations from the meta- analysis protocol, we conducted a sensitivity analysis by restricting the analysis to the original protocol criteria. This meant excluding studies which were not conducted in South Africa, including those designed as RCTs, and the ones which were published prior to year 2013. 3 Results 3.1 Study selection Out of the 24, 120 articles that were exported from the different databases, (6,601) were identified as duplicates. Of these, 3,444 were deleted while 3,157 were resolved, leaving a total of 20, 676 articles for screening. Of the 20,676 articles left for screening, 20 618 were excluded as they were not related to interventions for viral suppression or ART adherence. This left 58 full text articles for eligibility assessment, of which 43 were excluded due to the following reasons: foreign study setting (n = 20), wrong study population (n = 17), ineligible study design (n = 2), irrelevant outcome (n = 2), and unrelated study titles (n = 2). Of the 15 studies that were ultimately left for inclusion in the meta-analysis, Fig. 1 . 3.2 Study characteristics The 15 studies that were eligible for the meta-analysis were published between 2010 and 2024. These include six studies from Kenya (29,31–35), three from South Africa (36–38), two from Tanzania (39,40), and each of the last four conducted in Lesotho, Zimbabwe, Uganda, and Botswana (41–44). The studies comprised 13 RCTs (29,31,32,34,35,36,38–44), and two cohort studies (33,37). The studies had sample sizes ranging between 30 and 300 study participants, Table 1 . The interventions that were employed by the studies include incentive amounts, microfinance loans to purchase farming implements, and agricultural and farming training to improve food security, and household wealth (29,32,33,39,40,43), lay health worker-led weekly problem-solving therapy sessions and optional peer-led group support involved problem-solving therapy by lay counsellors, and training of treatment partners on providing non-directive support to patients using a non-confrontational and non-judgmental approach (31,34,35,42). Others were treatment option related interventions (37,41), and weekly SMS messages from clinic nurse and were required to respond within 48 hours (36). These interventions were categorised into FSI (Financial support interventions), PSI (Psychosocial support interventions), SDI (Specialised dispensing interventions), and BSI (Behavioral support intervention), respectively. The outcomes measures include improvement in VS and ART adherence. Eleven out of the 15 studies provided enough data for investigating VS (29,31,32,36,37,39–44), with only four which had data for th evaluation of ART adherence (29,32,42,44). Table 1 Characteristics of studies included in the sytematic review study of interventions to improve viral suppression among patients on antiretroviral therapy (ART) in Africa Author (Year) Country/ setting Study design Study population Control Type of intervention Main findings Borgat et al (2023) Botswana Mixed methods PLWH + treatment partners Standard of care (SoC) Multilevel adherence intervetion (MOPATI) Improved adherence; trends towards improved VS Jones et al (2018) South Africa Intervention Non -adherent ART patients Adherence counselling from the treating clinician Brief active visualisation intervention Improved adherence; viral suppression effects explored Amstutz et al (2021) Lesotho RCT Adults initiating ART same-day at home SoC Community health worker ART refill vs clinic-based refill following home based one day ART initiation Higher retention and viral suppression in CHW arm Kurth et al (2019) Kenya RCT Adults living with HIV Risk assessment only Computer-assisted counselling Improved self-care; modest VS benefits Basset et al., (2024) South Africa Cohort Adults on ART SoC Community vs. clinic -based medication pick up Variation in suppression by pick‑up point Njau et al., (2024) Tanzania RCT Adults initiating ART SoC Financial incentives Improved early viral suppression Fahey et al., (2020) Tanzania RCT Adults initiating ART SoC Incentives for retention in care and VS Significant improvement in VS. Positive trend identified between incentive size and viral suppression Lester et al., (2010) Kenya RCT Adults on ART SoC Weekly SMS messages from a clinc nurse (WelTel Kenya1) Improved adherence and VS Weiser et al., (2015) Kenya Cluster RCT Adults living with HIV SoC Irrigation pump, training, microfinance Improved food security and significant VS improvements. Thirumurthy et al., (2019) Uganda RCT HIV positive adults SoC Incentives for achieving/maintaining VS Significantly higher achievement & maintenance of VS Thapa et al., (2025) Kenya Cohort Adults on ART SoC Microfinance participation: GISHE membership Microfinance associated with higher suppression rates Haas et al., (2023) Zimbabwe RCT Rural ART patients SoC Problem-solving therapy by lay counsellors: Friendship bench Improved mental health and significantly improved VS Cohen et al., (2022)- Kenya Cluster RCT Adults living with HIV SoC Agricultural support package Significant improvements in VS and clinical outcomes Onoya et al., (2024) South Africa Cluster pilot RCT ART clinic patients SoC Lay counsellor motivational interviewing Improved retention and suppression trends Wachira et al., (2022) Kenya Quasi experiment/ intervention PLWH SoC Enhanced counselling + structured follow-up Higher VS in intervention vs. usual care 3.3 Risk of bias assessment Each of the RCT studies that were assessed using th RoB2 tool was independently assessed across predefined domains, with the disagreements resolved through discussion. Overall, the included intervention studies demonstrated generally low risk of bias across most domains, particularly for random sequence generation, detection bias, attrition bias, and selective reporting which were consistently rated as low risk (“+”) in the majority of studies, online supplemental table 1. Despite some concerns related to performance bias (34,36,38,44) and unclear allocation concealment (29,32,35,39,44), the overall methodological quality of the intervention studies was acceptable, and no study was excluded on the basis of high risk of bias. Online supplemental table 2 indicates that the two observational studies appraised using the JBI checklist (33,37), recruited participants from comparable populations and measured exposures and outcomes using valid and reliable methods. Exposure classification was applied consistently across exposed and unexposed groups in both studies. Appropriate statistical analyses were employed, and follow-up procedures were adequately described, with strategies implemented to address incomplete follow-up. However, important methodological differences were noted. Bassett et al. (2024) did not explicitly identify potential confounding factors, although strategies to address confounding were reported. Additionally, participants in this study were not free of the outcome at baseline, which may limit causal inference. In contrast, Thapa et al. (2025) clearly identified confounding factors and described strategies to address them, but information regarding baseline outcome status and the sufficiency of follow-up duration was unclear. Overall, both studies were judged to be of moderate to high methodological quality and were considered suitable for inclusion, although the noted limitations were taken into account when interpreting their findings. 3.4 Publication bias Figure 2 shows the funnel plots that were used for assessment of publication bias from the 11 studies and four studies that respectively analysed VS and ART adherence as the outcomes. The results from the VS studies indicate low likelihood of small study effect as shown by the large symmetrical distribution of studies around the pooled effect estimate. Whilst this warrants cautious interpretation, it does not nullify the overall finding, particularly given the low heterogeneity and consistency observed in primary analysis. On the contrary, the funnel plot relating to ART adherence outcome shows asymmetry, with smaller studies tending to report larger effect estimates. However, the interpretability of the funnel plot is limited, substantially, given that only four studies contributed to the analysis. As such, the observed asymmetry may reflect chance or clinical and methodological heterogeneity rather than true publication bias. 3.5 Overall effect of interventions on Viral suppression and ART adherence 3.5.1 Viral suppression Figure 3 is a forest plot showing the pooled effect of interventions on VS, (RR = 1.04; 95% CI: 1.02–1.06, I 2 = 18.90%), which indicates a statistically significant improvement in VS among the intervention group compared to SoC. Subgroup analysis shows BSIs as having the largest effect, RR = 1.18; 95% CI:1.01–1.39 with the intervention participants more likely to achieve VS compared to SoC. FSIs were also associated with a statistically significant improvement in VS, RR = 1.05; 95% CI:1.01–1.10, I 2 = 47.60%. On the contrary, PSIs and SDIs did not demonstrate statistically significant effect on VS respectively RR = 1.14; 95% CI:0.80–1.63, I 2 = 85.07,and RR = 1.04; 95% CI:0.99–1.09, I 2 = 0.01%. 3.5.2 ART adherence Figure 4 shows the pooled effect of the four studies that were investigated for the effectiveness of the interventions on ART adherence, RR = 1.05; CI:0.96–1.15, I 2 = 70.03%. Subgroup analysis revealed that BSIs had statistically significant effect in improvement in ART adherence, RR = 1.24; 95% CI: 1.06–1.44). In contrast, no statistically significant difference in effect was observed in ART adherence for FSIs and PSIs, respectively,(RR = 1.01;95% CI:0.98–1.03),and RR = 1.02; 95% CI: 0.90–1.15), I 2 = 38.73%. 3.5.3 Sensitivity analysis Table 2 shows the pooled effect of interventions on VS that was obtained after exclusion of studies that were not conducted in South Africa left two studies (36,37), RR = 1.37 (95% CI: 0.77–2.43), I 2 = 90.77% compared to the primary meta-analysis (pooled RR = 1.04), 95% CI: 1.02–1.06, I 2 = 18.90%. Omission of RCTs left only two studies, (37,44) which yielded a pooled RR = 0.98 (95% CI: 0.79–1.21), I 2 =55.23% with VS as the outcome. The study by Bogart et al. (2023) also had enough data for the analysis of treatment adherence as the outcome, RR = 1.16 (95% CI:0.97–1.38) compared to primary analysis RR = 1.05 (95% CI: 0.96–1.15). Restriction of the studies by year of publication (excluding studies published before 2013) left only one study, (31). This study was analysed for both VS treatment adherence as outcomes, yielding respectively; RR = 0.82 (95% CI: 0.60–1.13),and RR = 1.18 (95% CI: 1.01–1.39). Table 2 Sensitivity analysis of interventions on VS outcome Analysis No. of studies (RR),95% CI) Heterogeneity (I 2 ) Primary analysis 11 1.04 (1.02–1.06) 18.90% Omitting studies not done in SA 2 1.37 (0.77–2.43) 90.44% Excluding RCT studies 2 0.98 (0.79–1.21) 55.23% Excluding studies published before 2013 1 1.18 (1.01–1.39) - Model change (random -effects to fixed- effect model) 11 1.65 (1.59–1.70) 91.94% 4. Discussion This systematic review and meta-analysis study identified 15 studies for inclusion in the meta-analysis, of which only three had been conducted in South Africa. This highlights scarcity of high -quality targeted evidence evaluating the impact of interventions on VS in a South African setting. The results from the meta-analysis of 11 studies that were evaluated for effectiveness in improving VS demonstrate that the interventions were associated with improvement in VS. Although the magnitude of the pooled effect suggests modest improvement in VS, consistency of the findings across studies as indicated by low heterogeneity (I 2 = 18.90%), suggests that these interventions provide some reliable benefit at the population level. Small relative improvements in VS are clinically meaningful in HIV care because they translate into reduced transmission risk, lower morbidity and progress toward UNAIDS 95-95-95 targets, which is particularly relevant in high-burden settings such as South Africa (45,46). Switching the model from random effects to fixed effect resulted in increased pooled estimate, which was persistently statistically significant, with higher heterogeneity, (I 2 = 91.94%). This suggests that the larger studies reported higher effect than smaller studies, and that the findings remained robust and not sensitive to the choice of model. The modest increase in the pooled estimate and the loss of statistical significance that was observed when sensitivity analysis was restricted to studies done in South Africa, suggests that the excluded studies were either precise, large or had extreme effects which dominated the primary analysis. High heterogeneity could be due to the small number of studies that remained or it could be an indication of different populations, interventions or methodologies used across different settings. Subgroup analysis revealed variation in effectiveness by intervention type. BSI showed the greatest improvement in VS with likelihood of improved VS higher among participants who received weekly SMS from the clinic nurse compared to those in the SoC arm. This underscores the importance of directly targeting adherence, treatment literacy, and self-management skills. Barriers related to medication adherence behaviors such as disruption of people’s daily lives, forgetfulness, and treatment literacy play a central role in achieving sustained viral suppression. A study that was conducted in India has also reported an almost twice higher likelihood of viral suppression among adherence challenged participants who received behavioral adherence intervention than control participants (47, 48) The FSIs showed statistically significant improvement in VS, with moderate heterogeneity, I 2 = 47.60%, indicating some variability in effect across the studies, potentially reflecting differences in type, amount, or duration of the financial support provided. FSIs involving monetary incentives conditional to clinic attendance showed the greatest effect (39,40). This suggests that addressing structural barriers such as transport cost, and economic constraints can facilitate effective use of ART; modest financial incentives or support mechanisms may reduce economic barriers to consistent ART access, particularly in resource-limited settings, although moderate heterogeneity indicates variability in implementation and context. A systematic review and meta-analysis study which evaluated the effects of monetary incentives on VS and adherence involving 13 RCTs, reported significant improvement on these two key treatment goals (49). However, another study that was conducted among adults on highly active antiretroviral therapy (HAART) has reported no significant association between social support and VS (50). Although the pooled effect of PSIs did not demonstrate significant improvement on VS, one intervention involving training program for lay counsellors for attainment of MI skills showed statistically significant improvement in VS (36). PSIs may influence virologic outcomes indirectly through pathways such as mental health and social support which may require longer follow up to translate into measurable VS, as reflected by substantial heterogeneity across studies. A systematic review of studies conducted in the Unites States of America, and in a few countries in the sub-Saharan Africa (SSA) including South Africa, as well as Thailand found overall, small to moderate effects of PSIs on ART adherence, and VS among other outcomes (51). None of the SDIs showed a significant association with VS, which suggests that these interventions alone may not be sufficient to improve VS in the absence of complementary behavioral or structural components. The non-significant pooled effect of interventions on ART adherence highlights the complex and context dependent nature of adherence behaviors, and this coupled with the observed substantial heterogeneity (I 2 = 70.03%) in the overall analysis suggests that intervention effectiveness is not uniform, and that aggregating diverse approaches may obscure benefits seen in specific intervention categories. The significant effect of BSIs aligns with existing evidence that interventions addressing practical adherence skills, motivation and routine building such as counselling, reminders and structural adherence support among ART patients are more likely to influence treatment taking behavior (52). These interventions may directly influence proximal determinants of adherence such as forgetfulness, treatment fatigue, thereby producing measurable improvements. 5. Strengths and limitations Expansion of the eligibility criteria following an empty review potentially introduced additional heterogeneity, contextually and methodologically. However, with ART delivery frameworks and the WHO aligned treatment guidelines shared across many African countries (53), the broader inclusion possibly allowed for a more comprehensive synthesis of the available evidence while maintaining conceptual consistency with the original objectives. Exclusion of studies which were not written in English, may have resulted in potentially relevant findings being overlooked. Additionally, this could result in missing out on diverse perspectives especially from countries in the Sub-Saharan region with HIV epidemiology similar to that of South Africa. Exclusion of the four studies from the meta-analysis due to providing insufficient reporting of quantitative outcome data required for effect size estimation, may have reduced the completeness of data synthesis and may have influenced the precision of the pooled effect estimates. This review, however, adhered to a registered protocol and followed the PRISMA guidelines to ensure transparency and reproducibility. 6. Conclusion In summary, this meta-analysis provides evidence that ART-related interventions, particularly those incorporating behavioral, and financial support contribute to improved VS. These findings underscore the importance of addressing both individual-level behaviors and structural barriers in HIV treatment programmes, while highlighting the need for further high-quality studies to clarify the role of psychosocial and service-delivery interventions (SDIs). PSIs can be more effective when implemented as part of multi-component strategies rather than as standalone approaches. SDIs are likely to be more effective as maintenance strategies within stable populations or within broader multilevel adherence frameworks. These findings reinforce the need for targeted, risk-stratified approaches within ART programmes, whereby patients with unsuppressed viral loads receive intensified behavioral and structural support alongside routine service delivery adaptations. Abbreviations ART Antiretroviral therapy BSIs Behavioral support interventions DSD Differentiated service delivery FSIs Financial support interventions HAART Highly active antiretroviral therapy HIV Human Immunodeficiency virus JBI Joanna Briggs Institute KPs Key populations LE Life expectancy LMIC Low-and-middle income countries MSM Men who have sex with men PLWH People living with HIV PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis PSIs Psychosocial support interventions PWID People who inject drugs RCT Randomized controlled trial RR Risk ratio RoB 2 Cochrane’s Risk of Bias 2.0 SDIs Specialized dispensing interventions SoC Standard of care SSA Sub Saharan Africa STIs Sexually transmitted infections TB Tuberculosis TGW Transgender women VR Viral rebound VS Viral suppression Declarations 7. Ethical considerations This study was ethically cleared by the research ethics committee of Sefako Makgatho health sciences university, SMUREC/H/31/2024:PG. As this study is a systematic review of previously published studies, no informed consent was required from primary participants 8. Data Availability Statement The data files generated and analysed during the current study are available from the corresponding author upon request 9. Author Contributions LC: Conceptualization, Methodology, Data curation, Investigation, Formal Analysis, Writing–original draft. M.M.: Conceptualization, Methodology, Formal Analysis, Supervision, Validation, Writing – review & editing. OO: Methodology, Formal Analysis, Supervision, Validation, Writing–review & editing. All authors have read and agreed to the published version of the manuscript 10. Funding This research received no external funding 11. Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. 12. 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Opoku S, Sakyi SA, Ayisi-Boateng NK, Enimil AK, Senu E, Ansah RO, Aning BD, Ojuang DA, Wekesa DN, Ahmed FO, Okeke CB. Factors associated with viral suppression and rebound among adult HIV patients on treatment: a retrospective study in Ghana. AIDS Research and Therapy. 2022 May 25;19(1):21. 19. Kirabira A, Bukenya J, Ssenkusu J, Ssekamatte NK, Tumwesigye NM, Kiwanuka N. PREDICTORS OF VIRAL REBOUND AMONG ADOLESCENTS AT AN URBAN CLINIC IN KAMPALA USING REPEATED EVENTS SURVIVAL ANALYSIS. medRxiv. 2024 Jul 29:2024-07. 20. Mpolya EA. A prospective study for predictors of HIV viral load rebound in an HIV hyperendemic rural population of KwaZulu-Natal, South Africa. PAMJ-One Health. 2023 Aug 2;11(13). 21. Azia IN, Mukumbang FC, Van Wyk B. Barriers to adherence to antiretroviral treatment in a regional hospital in Vredenburg, Western Cape, South Africa. Southern African journal of HIV medicine. 2016 Jan 1;17(1):1–8. 22. Magura J, Nhari SR, Nzimakwe TI. Barriers to ART adherence in sub-Saharan Africa: a scoping review toward achieving UNAIDS 95-95-95 targets. Frontiers in Public Health. 2025 Jun 10;13:1609743. 23. Ukoaka BM, Ugwuanyi EA, Ukueku KO, Ajah KU, Udam NG, Daniel FM, Wali TA, Gbuchie MA. Digital tools for improving antiretroviral adherence among people living with HIV in Africa. Journal of Medicine, Surgery, and Public Health. 2024 Apr 1;2:100077. 24. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al, editor(s). Cochrane Handbook for Systematic Reviews of Interventions version 6.5 (updated August 2024). Cochrane, 2024. Available from www.cochrane.org/handbook. 25. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. bmj. 2021 Mar 29;372. 26. Cele L, Mokgatle MM, Oladimeji O. Systematic review and meta-analysis protocol of patient-centred interventions for sustained viral suppression among patients on antiretroviral therapy in South Africa. BMJ open. 2025 Mar 1;15(3):e087369. 27. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng H-Y, Corbett MS, Eldridge SM, Hernán MA, Hopewell S, Hróbjartsson A, Junqueira DR, Jüni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366 : l4898. 28. Joanna Briggs Institute. Checklist for cohort studies: Critical Appraisal tools for use in JBI Systematic Reviews: Joanna Briggs Institute; 2020 [Internet]. https://jbi.global/sites/default/files/2020-08/Checklist_for_Cohort_Studies.pdf. [Accessed on January 20, 2026]. 29. Weiser SD, Bukusi EA, Steinfeld RL, Frongillo EA, Weke E, Dworkin SL, Pusateri K, Shiboski S, Scow K, Butler LM, Cohen CR. Shamba Maisha: randomized controlled trial of an agricultural and finance intervention to improve HIV health outcomes. Aids. 2015 Sep 10;29(14):1889-94. 30. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. bmj. 2003 Sep 4;327(7414):557 − 60. 31. Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. The Lancet. 2010 Nov 27;376(9755):1838-45. 32. Cohen CR, Weke E, Frongillo EA, Sheira LA, Burger R, Mocello AR, Wekesa P, Fisher M, Scow K, Thirumurthy H, Dworkin SL. Effect of a multisectoral agricultural intervention on HIV health outcomes among adults in Kenya: a cluster randomized clinical trial. JAMA Network Open. 2022 Dec 12;5(12):e2246158. 33. Thapa BB, Genberg B, Wachira J, Steingrimsson J, Galarraga O. Is membership in microfinance initiatives associated with viral load suppression among HIV patients? Evidence from western Kenya. BMC Global and Public Health. 2025 Jun 25;3(1):55. 34. Kurth AE, Sidle JE, Chhun N, Lizcano JA, Macharia SM, Garcia MM, Mwangi A, Keter A, Siika AM. Computer-based counseling program (CARE+ Kenya) to promote prevention and HIV health for people living with HIV/AIDS: a randomized controlled trial. AIDS Education and Prevention. 2019 Oct;31(5):395–406. 35. Wachira J, Genberg B, Mwangi A, Chemutai D, Braitstein P, Galarraga O, Siika A, Wilson I. Impact of an enhanced patient care intervention on viral suppression among patients living with HIV in Kenya. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2022 Aug 1;90(4):434-9. 36. Onoya D, Sineke T, Mokhele I, Vujovic M, Holland K, Ruiter RA. Improving Retention and HIV Viral Suppression: A Cluster Randomised Pilot Trial of a Lay Counsellor Motivational Interviewing Training in South Africa. medRxiv. 2024 Sep 23. 37. Bassett IV, Yan J, Govere S, Khumalo A, Shazi Z, Nzuza M, Aung T, Rahman K, Zionts D, Dube N, Tshabalala S. Does type of antiretroviral therapy pick-up point influence 12-month virologic suppression in South Africa? AIDS care. 2024 Oct 2;36(10):1518-27. 38. Jones AS, Coetzee B, Kagee A, Fernandez J, Cleveland E, Thomas M, Petrie KJ. The use of a brief, active visualisation intervention to improve adherence to antiretroviral therapy in non-adherent patients in South Africa. AIDS and Behavior. 2019 Aug 15;23(8):2121-9. 39. Njau PF, Katabaro E, Winters S, Sabasaba A, Hassan K, Joseph B, Maila H, Msasa J, Fahey CA, Packel L, Dow WH. Impact of financial incentives on viral suppression among adults initiating HIV treatment in Tanzania: a hybrid effectiveness–implementation trial. The Lancet HIV. 2024 Sep 1;11(9):e586-97. 40. Fahey CA, Njau PF, Katabaro E, Mfaume RS, Ulenga N, Mwenda N, Bradshaw PT, Dow WH, Padian NS, Jewell NP, McCoy SI. Financial incentives to promote retention in care and viral suppression in adults with HIV initiating antiretroviral therapy in Tanzania: a three-arm randomised controlled trial. The Lancet HIV. 2020 Nov 1;7(11):e762-71. 41. Amstutz A, Lejone TI, Khesa L, Kopo M, Kao M, Muhairwe J, Bresser M, Räber F, Klimkait T, Battegay M, Glass TR. Offering ART refill through community health workers versus clinic-based follow-up after home-based same-day ART initiation in rural Lesotho: The VIBRA cluster-randomized clinical trial. PLoS medicine. 2021 Oct 21;18(10):e1003839. 42. Haas AD, Kunzekwenyika C, Manzero J, Hossmann S, Limacher A, van Dijk JH, Manhibi R, von Groote P, Hobbins MA, Verhey R, Egger M. Effect of the Friendship Bench intervention on antiretroviral therapy outcomes and mental health symptoms in rural Zimbabwe: A cluster randomized trial. JAMA Network Open. 2023 Jul 13;6(7):e2323205. 43. Thirumurthy H, Ndyabakira A, Marson K, Emperador D, Kamya M, Havlir D, Kwarisiima D, Chamie G. Financial incentives for achieving and maintaining viral suppression among HIV-positive adults in Uganda: a randomised controlled trial. The lancet HIV. 2019 Mar 1;6(3):e155-63. 44. Bogart LM, Phaladze N, Kgotlaetsile K, Klein DJ, Goggin K, Mosepele M. Pilot test of Mopati, a multi-level adherence intervention for people living with HIV and their treatment partners in Botswana. International Journal of Behavioral Medicine. 2024 Oct;31(5):787 − 98. 45. World Health Organization. The role of HIV viral suppression in improving individual health and reducing transmission. 2023 Jul 22. https://www.who.int/publications/i/item/9789240055179. [Accessed January 19,2026] 46. Allinder SM, Fleischman J. The world’s largest HIV epidemic in crisis: HIV in South Africa. Center for strategic and international studies. 2019 Apr 2;2:2019. 47. Ekstrand ML, Heylen E, Pereira M, D’Souza J, Nair S, Mazur A, Shamsundar R, Kumar BR, Chandy S. A behavioral adherence intervention improves rates of viral suppression among adherence-challenged people living with HIV in South India. AIDS and Behavior. 2020 Jul;24(7):2195 − 205. 48. Gwadz M, Cleland CM, Applegate E, Belkin M, Gandhi M, Salomon N, Banfield A, Leonard N, Riedel M, Wolfe H, Pickens I. Behavioral intervention improves treatment outcomes among HIV-infected individuals who have delayed, declined, or discontinued antiretroviral therapy: a randomized controlled trial of a novel intervention. AIDS and Behavior. 2015 Oct;19(10):1801-17. 49. Zhu Z, Guo L, Yang M, Cheng J. The effectiveness of monetary incentives in improving viral suppression, treatment adherence, and retention in care among the general population of people living with HIV: a systematic review and meta-analysis. AIDS Research and Therapy. 2025 Jun 2;22(1):57. 50. Habte, T. M., Bondo, C., & Nkombua, L. (2020). Association between social support and viral load in adults on highly active antiretroviral therapy–Witbank, South Africa. South African Family Practice , 62 (4). 51. Laurenzi CA, du Toit S, Ameyan W, Melendez-Torres GJ, Kara T, Brand A, Chideya Y, Abrahams N, Bradshaw M, Page DT, Ford N. 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. Journal of the International AIDS Society. 2021 Aug;24(8):e25741. 52. Greenley RN, Kunz JH, Walter J, Hommel KA. Practical strategies for enhancing adherence to treatment regimen in inflammatory bowel disease. Inflammatory bowel diseases. 2013 Jun 1;19(7):1534-45. 53. Scheier TC, Tufa TB, Feldt T, Hardy Y, Minga A, Moh R, Damasceno A, Chambal L, Ntoumi F, Kades C, Bitunguhari L. Standard of care in advanced HIV disease: review of HIV treatment guidelines in sub-Saharan African countries—an extension study of eight countries. AIDS Research and Therapy. 2025 Mar 29;22(1):39. Additional Declarations The authors declare no competing interests. Supplementary Files Searchstrategy26072025TableA.docx Table A: Search strategy QualityAppraisalTablesB1B2.docx Table B1:Appraisal checklist for non-randomized study designs Table B 2: Quality appraisal for randomized controlled trials (RCTs) Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":105422,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eForest plot of studies included in the systematic review and metanalysis of interventions to improve adherence among adult patients on ART\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9574334/v1/594737527505fcbbe855ef47.png\"},{\"id\":108803607,\"identity\":\"5e309480-87e3-4525-a04c-af11453bdcd2\",\"added_by\":\"auto\",\"created_at\":\"2026-05-08 15:00:24\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":734012,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9574334/v1/fa20ec79-7549-45de-833d-6f2238475e41.pdf\"},{\"id\":108493169,\"identity\":\"ba7272dc-aa14-409e-b983-61a8ee9c69e5\",\"added_by\":\"auto\",\"created_at\":\"2026-05-05 09:59:32\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":20920,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eTable A: Search strategy\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Searchstrategy26072025TableA.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9574334/v1/aea2545adaaeb2fc6d005b8a.docx\"},{\"id\":108493209,\"identity\":\"c9ffe713-0ff9-47e1-aba5-f7dbe36ab3a3\",\"added_by\":\"auto\",\"created_at\":\"2026-05-05 09:59:41\",\"extension\":\"docx\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":18599,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eTable B1:Appraisal checklist for non-randomized study designs\\u003c/p\\u003e\\n\\u003cp\\u003eTable B 2: Quality appraisal for randomized controlled trials (RCTs)\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"QualityAppraisalTablesB1B2.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9574334/v1/60643d377bfd0ab0059dac14.docx\"}],\"financialInterests\":\"The authors declare no competing interests.\",\"formattedTitle\":\"\\u003cp\\u003eInterventions to improve viral suppression in antiretroviral therapy patients in Africa: A Systematic Review and Meta analysis\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"1. Introduction\",\"content\":\"\\u003cp\\u003eHuman immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) continue to be a major global public health concern, with 40.8\\u0026nbsp;million people said to be living with HIV (PLWH), in 2024, worldwide, and 693 000 AIDS related deaths occurring in the same year (1). The African continent bears a disproportionate share of the global burden, accounting for nearly two-thirds of all PLWH (2).Although the widespread scale-up of antiretroviral therapy (ART) has resulted in substantial reduction in HIV related morbidity and mortality, the epidemic remains concentrated in specific regions and populations (3,4).\\u003c/p\\u003e \\u003cp\\u003eSouth Africa has one of the highest HIV prevalence in the world with approximately 7.8\\u0026nbsp;million PLWH in 2022. ART is widely available in the country, with an estimated 5 730 647 of the 7.8\\u0026nbsp;million PLWH receiving treatment in the same year, 2022 (5,6,7). HIV transmission in South Africa is predominantly heterosexual, characterized by pronounced gender and age disparities. Women, particularly aged 25\\u0026ndash;29 years, experience disproportionately high HIV incidence, driven by biological susceptibility, socioeconomic inequality, gender-based violence, and structural barriers to prevention and care (8,9).\\u003c/p\\u003e \\u003cp\\u003eAlthough nationwide implementation of ART has potentially transformed HIV into chronic, and manageable condition in South Africa, resulting in significant reduction in AIDS-related mortality and improvements in life expectancy, challenges of treatment adherence hinder progress in the ART program (10,11,12). Studies conducted in some parts of the country have reported suboptimal ART adherence and high default rates among participants on ART (13,14,15). Progress towards the 95-95-95 targets indicates that South Africa had 89.6% of PLWH who knew their HIV status, of which 90.7% were on ART, and 93.9% of whom were virally suppressed, in 2022 (16).\\u003c/p\\u003e \\u003cp\\u003eThe clinical and public health benefits of ART are largely dependent on achievement and maintenance of viral suppression (VS), the primary indicator of treatment effectiveness. Sustained VS reduces the risk of disease progression, emergence of drug resistance and viral transmission (17). However, VS is not consistently maintained among all patients receiving ART in routine program settings in Africa, with patient, treatment and health system related factors contributing to suboptimal outcomes (18,19,20). Persistent challenges related to adherence and viral suppression highlight the importance of behavioral, psychosocial, and structural determinants of HIV outcomes.\\u003c/p\\u003e \\u003cp\\u003eStigma, mental health conditions, food insecurity, limited social support, and health system constraints continue to influence adherence behaviors in high-burden settings (21,13,22). In response, a wide range of interventions including adherence support strategies, differentiated service delivery models, community-based interventions, and digital health approaches have been implemented to improve VS among patients on ART in Africa (23). While individual studies have reported results of varying degree of their effectiveness, evidence remains fragmented and heterogenous, making it difficult to draw definitive conclusions regarding which interventions are most effective across different settings and populations.\\u003c/p\\u003e \\u003cp\\u003eThis systematic review and meta-analysis (SR and MA) study synthesized available data on interventions designed to improve VS among adult patients on ART in Africa. The findings will help inform policy, program implementation, and future research.\\u003c/p\\u003e\"},{\"header\":\"2. Materials and Methods\",\"content\":\"\\u003cp\\u003eThis systematic review and meta- analysis study was performed based on the Cochrane Handbook for Systematic Reviews of Interventions (24). We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline of 2020 (25). The study protocol was registered in PROSPERO: CRD42024532244.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eProtocol deviation\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThis review was conducted in accordance with a previously published protocol (26) which restricted eligibility to studies conducted in South Africa, observational in design, and published between 2013 and 2024. The initial searches yielded no eligible studies (empty review), and this resulted in the review team broadening the eligibility criteria to enhance feasibility and ensure a meaningful synthesis of evidence. The amendment includes expansion of the geographic scope from South Africa to Africa, modification of study designs to include intervention studies, and extension of the publication year limits from 2013\\u0026ndash;2024 to 2003\\u0026ndash;2025, with the consequent adjustment of the data collection period from March 2025 to July 2025. These amendments were made following confirmation of an empty review and were not influenced by outcome data or study findings\\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.1 Literature search strategy\\u003c/h2\\u003e \\u003cp\\u003eA literature search was conducted in July 2025, using Pubmed, and EbscoHost (CINHAL and Medline) electronic databases. We used the study question: (What interventions are in place for sustaining viral suppression among adult patients who are on antiretroviral therapy) to identify key concepts (interventions AND antiretroviral therapy AND viral suppression). For comprehensiveness, keywords were formulated from each of the key concepts using a combination of Medical Search Headings (MeSH) and free text terms adapted according to each database. The search terms were combined using the Boolean operators (AND, OR, NOT). We applied search filters and limits within the search interface of each database including the year of publication (2003\\u0026ndash;2025), place of publication (Africa),language restriction (English),and publication type (research articles). Search strategies were translated according to each database vocabulary and operators (Boolean, wildcard, proximity etc.),online supplementary table 1.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.2 Eligibility criteria\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003e2.2.1 Inclusion Criteria\\u003c/h2\\u003e \\u003cp\\u003eThe studies were included if they were conducted in countries that are in the African continent, published in peer reviewed journals between the year 2003 and 2025, and if the intervention was community-based, behavioral, psychosocial, digital health, health system, or structural.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003e2.2.2 Exclusion Criteria\\u003c/h2\\u003e \\u003cp\\u003eThe studies were excluded if they were conducted among patients who were aged younger than 18 years, and designed as systematic reviews or clinical trials, or when the outcome measure was not related to viral suppression and or ART adherence. Studies were also excluded if they were qualitative in nature, and when they lacked quantitative detail for the calculation of the effect sizes, and if there was no detailed description of the intervention.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003e2.2.3 Article screening and selection\\u003c/h2\\u003e \\u003cp\\u003eAll retrieved studies were managed using the Rayyan software where duplicate detection and removal, including article screening were done. Two reviewers, L.C and L.N, worked independently to screen through study titles and abstracts whilst applying inclusion and exclusion criteria. Conflicting decisions between the reviewers were dealt with by comparing independent reviewer decisions, with each reviewer changing their decision as needed, through consensus. For full text screening, all included studies were filtered through the citation display. The generated results are displayed in a PRISMA flow diagram, Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.3 Data extraction\\u003c/h2\\u003e \\u003cp\\u003eTwo reviewers, L.C and L.N independently used the extraction tool that was designed to collect the information from the selected studies, which includes author name (s), year of publication, study location or country, study design, number of events (intervention and control participants), total number of participants, intervention type, outcome measurements, viral load threshold, ART duration, and the point estimates with the corresponding 95% confidence intervals (95% CI).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.4 Quality assessment\\u003c/h2\\u003e \\u003cp\\u003eWe used the Cochrane criteria for the systematic assessment of risk of bias in randomized controlled trials (RCTs) and Quasi experiment/ intervention studies, the Cochrane Risk of Bias tool (RoB 2), and Joanna Briggs Institute (JBI) checklist for cohort studies (27, 28). Each study was independently assessed across predefined domains, with disagreements resolved through discussion. Based on the risk of bias assessment, the overall quality of studies was graded as low, medium or high risk, supplementary tables 2 and 3.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2.5 Data synthesis and analysis\\u003c/h2\\u003e \\u003cp\\u003eThe extracted data were captured onto Microsoft Excel spreadsheet, and these were analyzed on Stata version 17 using the Random Effects Model Maximum Likelihood method. The meta-analysis included studies that reported the number of events and the total number of participants by control and intervention arm for VS and ART adherence outcomes. For VS, threshold values varied; one was study specific, using 40copies/ml (29), with the other 10 being context specific based on the country and/or WHO definition of VS at the time of the study (50 copies/ ml, 200 copies/ ml, 400 copies/ml, and 1000 copies/ml). The high ART adherence ranged between 80% and 100%. The duration of the measured outcomes (viral suppression and ART adherence) ranged between 6 and 24 months.\\u003c/p\\u003e \\u003cp\\u003eWe conducted subgroup analysis using the intervention type groupings (behavioral support (BSI), financial support (FSI), psychosocial support (PSI), and specialized dispensing (SDI)). Risk ratios (RR) were calculated to determine the effectiveness of the interventions including the 95% confidence intervals (95% CIs), and the weight proportion that each study contributed, and these were displayed on forest plots. We used Cochran\\u0026rsquo;s Q and I\\u003csup\\u003e2\\u003c/sup\\u003e to assess heterogeneity of the studies; I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;50% considered low, 50%-70% considered moderate and \\u0026gt;\\u0026thinsp;75% considered high heterogeneity (30). Publication bias was assessed using the Funnel plots.\\u003c/p\\u003e \\u003cp\\u003eTo explore the impact of deviations from the meta- analysis protocol, we conducted a sensitivity analysis by restricting the analysis to the original protocol criteria. This meant excluding studies which were not conducted in South Africa, including those designed as RCTs, and the ones which were published prior to year 2013.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"3 Results\",\"content\":\"\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.1 Study selection\\u003c/h2\\u003e \\u003cp\\u003eOut of the 24, 120 articles that were exported from the different databases, (6,601) were identified as duplicates. Of these, 3,444 were deleted while 3,157 were resolved, leaving a total of 20, 676 articles for screening. Of the 20,676 articles left for screening, 20 618 were excluded as they were not related to interventions for viral suppression or ART adherence. This left 58 full text articles for eligibility assessment, of which 43 were excluded due to the following reasons: foreign study setting (n\\u0026thinsp;=\\u0026thinsp;20), wrong study population (n\\u0026thinsp;=\\u0026thinsp;17), ineligible study design (n\\u0026thinsp;=\\u0026thinsp;2), irrelevant outcome (n\\u0026thinsp;=\\u0026thinsp;2), and unrelated study titles (n\\u0026thinsp;=\\u0026thinsp;2). Of the 15 studies that were ultimately left for inclusion in the meta-analysis, Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.2 Study characteristics\\u003c/h2\\u003e \\u003cp\\u003eThe 15 studies that were eligible for the meta-analysis were published between 2010 and 2024. These include six studies from Kenya (29,31\\u0026ndash;35), three from South Africa (36\\u0026ndash;38), two from Tanzania (39,40), and each of the last four conducted in Lesotho, Zimbabwe, Uganda, and Botswana (41\\u0026ndash;44). The studies comprised 13 RCTs (29,31,32,34,35,36,38\\u0026ndash;44), and two cohort studies (33,37). The studies had sample sizes ranging between 30 and 300 study participants, Table\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe interventions that were employed by the studies include incentive amounts, microfinance loans to purchase farming implements, and agricultural and farming training to improve food security, and household wealth (29,32,33,39,40,43), lay health worker-led weekly problem-solving therapy sessions and optional peer-led group support involved problem-solving therapy by lay counsellors, and training of treatment partners on providing non-directive support to patients using a non-confrontational and non-judgmental approach (31,34,35,42). Others were treatment option related interventions (37,41), and weekly SMS messages from clinic nurse and were required to respond within 48 hours (36). These interventions were categorised into FSI (Financial support interventions), PSI (Psychosocial support interventions), SDI (Specialised dispensing interventions), and BSI (Behavioral support intervention), respectively.\\u003c/p\\u003e \\u003cp\\u003eThe outcomes measures include improvement in VS and ART adherence. Eleven out of the 15 studies provided enough data for investigating VS (29,31,32,36,37,39\\u0026ndash;44), with only four which had data for th evaluation of ART adherence (29,32,42,44).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eCharacteristics of studies included in the sytematic review study of interventions to improve viral suppression among patients on antiretroviral therapy (ART) in Africa\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAuthor (Year)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCountry/ setting\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStudy design\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eStudy population\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eControl\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eType of intervention\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMain findings\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBorgat et al (2023)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eBotswana\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMixed methods\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePLWH\\u0026thinsp;+\\u0026thinsp;treatment partners\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eStandard of care (SoC)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMultilevel adherence intervetion (MOPATI)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eImproved adherence; trends towards improved VS\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eJones et al (2018)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSouth Africa\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eIntervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eNon -adherent ART patients\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eAdherence counselling\\u003c/p\\u003e \\u003cp\\u003efrom the treating clinician\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eBrief active visualisation intervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eImproved adherence; viral suppression effects explored\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAmstutz et al (2021)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLesotho\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAdults initiating ART same-day at home\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eCommunity health worker ART refill vs clinic-based refill following home based one day ART initiation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigher retention and viral suppression in CHW arm\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eKurth et al (2019)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eKenya\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAdults living with HIV\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eRisk assessment only\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eComputer-assisted counselling\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eImproved self-care; modest VS benefits\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBasset et al., (2024)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSouth Africa\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCohort\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAdults on ART\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eCommunity vs. clinic -based medication pick up\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eVariation in suppression by pick‑up point\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNjau et al., (2024)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTanzania\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAdults initiating ART\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eFinancial incentives\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eImproved early viral suppression\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFahey et al., (2020)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTanzania\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAdults initiating ART\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eIncentives for retention in care and VS\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eSignificant improvement in VS. Positive trend identified between incentive size and viral suppression\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLester et al., (2010)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eKenya\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAdults on ART\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eWeekly SMS messages from a clinc nurse (WelTel Kenya1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eImproved adherence and VS\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWeiser et al., (2015)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eKenya\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCluster RCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAdults living with HIV\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eIrrigation pump, training, microfinance\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eImproved food security and significant VS improvements.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThirumurthy et al., (2019)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eUganda\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eHIV positive adults\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eIncentives for achieving/maintaining VS\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eSignificantly higher achievement \\u0026amp; maintenance of VS\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThapa et al., (2025)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eKenya\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCohort\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAdults on ART\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMicrofinance participation: GISHE membership\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eMicrofinance associated with higher suppression rates\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHaas et al., (2023)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eZimbabwe\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eRural ART patients\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eProblem-solving therapy by lay counsellors: Friendship bench\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eImproved mental health and significantly improved VS\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCohen et al., (2022)-\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eKenya\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCluster RCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAdults living with HIV\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eAgricultural support package\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eSignificant improvements in VS and clinical outcomes\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOnoya et al., (2024)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSouth Africa\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCluster pilot RCT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eART clinic patients\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eLay counsellor motivational interviewing\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eImproved retention and suppression trends\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWachira et al., (2022)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eKenya\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eQuasi experiment/ intervention\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePLWH\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSoC\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eEnhanced counselling\\u0026thinsp;+\\u0026thinsp;structured follow-up\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eHigher VS in intervention vs. usual care\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.3 Risk of bias assessment\\u003c/h2\\u003e \\u003cp\\u003eEach of the RCT studies that were assessed using th RoB2 tool was independently assessed across predefined domains, with the disagreements resolved through discussion. Overall, the included intervention studies demonstrated generally low risk of bias across most domains, particularly for random sequence generation, detection bias, attrition bias, and selective reporting which were consistently rated as low risk (\\u0026ldquo;+\\u0026rdquo;) in the majority of studies, online supplemental table 1. Despite some concerns related to performance bias (34,36,38,44) and unclear allocation concealment (29,32,35,39,44), the overall methodological quality of the intervention studies was acceptable, and no study was excluded on the basis of high risk of bias.\\u003c/p\\u003e \\u003cp\\u003eOnline supplemental table 2 indicates that the two observational studies appraised using the JBI checklist (33,37), recruited participants from comparable populations and measured exposures and outcomes using valid and reliable methods. Exposure classification was applied consistently across exposed and unexposed groups in both studies. Appropriate statistical analyses were employed, and follow-up procedures were adequately described, with strategies implemented to address incomplete follow-up. However, important methodological differences were noted. Bassett et al. (2024) did not explicitly identify potential confounding factors, although strategies to address confounding were reported. Additionally, participants in this study were not free of the outcome at baseline, which may limit causal inference. In contrast, Thapa et al. (2025) clearly identified confounding factors and described strategies to address them, but information regarding baseline outcome status and the sufficiency of follow-up duration was unclear. Overall, both studies were judged to be of moderate to high methodological quality and were considered suitable for inclusion, although the noted limitations were taken into account when interpreting their findings.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.4 Publication bias\\u003c/h2\\u003e \\u003cp\\u003eFigure \\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e shows the funnel plots that were used for assessment of publication bias from the 11 studies and four studies that respectively analysed VS and ART adherence as the outcomes. The results from the VS studies indicate low likelihood of small study effect as shown by the large symmetrical distribution of studies around the pooled effect estimate. Whilst this warrants cautious interpretation, it does not nullify the overall finding, particularly given the low heterogeneity and consistency observed in primary analysis. On the contrary, the funnel plot relating to ART adherence outcome shows asymmetry, with smaller studies tending to report larger effect estimates. However, the interpretability of the funnel plot is limited, substantially, given that only four studies contributed to the analysis. As such, the observed asymmetry may reflect chance or clinical and methodological heterogeneity rather than true publication bias.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.5 Overall effect of interventions on Viral suppression and ART adherence\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003e3.5.1 Viral suppression\\u003c/h2\\u003e \\u003cp\\u003eFigure \\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e is a forest plot showing the pooled effect of interventions on VS, (RR\\u0026thinsp;=\\u0026thinsp;1.04; 95% CI: 1.02\\u0026ndash;1.06, I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;18.90%), which indicates a statistically significant improvement in VS among the intervention group compared to SoC. Subgroup analysis shows BSIs as having the largest effect, RR\\u0026thinsp;=\\u0026thinsp;1.18; 95% CI:1.01\\u0026ndash;1.39 with the intervention participants more likely to achieve VS compared to SoC. FSIs were also associated with a statistically significant improvement in VS, RR\\u0026thinsp;=\\u0026thinsp;1.05; 95% CI:1.01\\u0026ndash;1.10, I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;47.60%. On the contrary, PSIs and SDIs did not demonstrate statistically significant effect on VS respectively RR\\u0026thinsp;=\\u0026thinsp;1.14; 95% CI:0.80\\u0026ndash;1.63, I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;85.07,and RR\\u0026thinsp;=\\u0026thinsp;1.04; 95% CI:0.99\\u0026ndash;1.09, I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;0.01%.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec18\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003e3.5.2 ART adherence\\u003c/h2\\u003e \\u003cp\\u003eFigure \\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e shows the pooled effect of the four studies that were investigated for the effectiveness of the interventions on ART adherence, RR\\u0026thinsp;=\\u0026thinsp;1.05; CI:0.96\\u0026ndash;1.15, I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;70.03%. Subgroup analysis revealed that BSIs had statistically significant effect in improvement in ART adherence, RR\\u0026thinsp;=\\u0026thinsp;1.24; 95% CI: 1.06\\u0026ndash;1.44). In contrast, no statistically significant difference in effect was observed in ART adherence for FSIs and PSIs, respectively,(RR\\u0026thinsp;=\\u0026thinsp;1.01;95% CI:0.98\\u0026ndash;1.03),and RR\\u0026thinsp;=\\u0026thinsp;1.02; 95% CI: 0.90\\u0026ndash;1.15), I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;38.73%.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec19\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003e3.5.3 Sensitivity analysis\\u003c/h2\\u003e \\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e shows the pooled effect of interventions on VS that was obtained after exclusion of studies that were not conducted in South Africa left two studies (36,37), RR\\u0026thinsp;=\\u0026thinsp;1.37 (95% CI: 0.77\\u0026ndash;2.43), I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;90.77% compared to the primary meta-analysis (pooled RR\\u0026thinsp;=\\u0026thinsp;1.04), 95% CI: 1.02\\u0026ndash;1.06, I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;18.90%. Omission of RCTs left only two studies, (37,44) which yielded a pooled RR\\u0026thinsp;=\\u0026thinsp;0.98 (95% CI: 0.79\\u0026ndash;1.21), I\\u003csup\\u003e2\\u003c/sup\\u003e =55.23% with VS as the outcome. The study by Bogart et al. (2023) also had enough data for the analysis of treatment adherence as the outcome, RR\\u0026thinsp;=\\u0026thinsp;1.16 (95% CI:0.97\\u0026ndash;1.38) compared to primary analysis RR\\u0026thinsp;=\\u0026thinsp;1.05 (95% CI: 0.96\\u0026ndash;1.15). Restriction of the studies by year of publication (excluding studies published before 2013) left only one study, (31). This study was analysed for both VS treatment adherence as outcomes, yielding respectively; RR\\u0026thinsp;=\\u0026thinsp;0.82 (95% CI: 0.60\\u0026ndash;1.13),and RR\\u0026thinsp;=\\u0026thinsp;1.18 (95% CI: 1.01\\u0026ndash;1.39).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eSensitivity analysis of interventions on VS outcome\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAnalysis\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNo. of studies\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e(RR),95% CI)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eHeterogeneity (I\\u003csup\\u003e2\\u003c/sup\\u003e)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePrimary analysis\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.04 (1.02\\u0026ndash;1.06)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e18.90%\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOmitting studies not done in SA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.37 (0.77\\u0026ndash;2.43)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e90.44%\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eExcluding RCT studies\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.98 (0.79\\u0026ndash;1.21)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e55.23%\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eExcluding studies published before 2013\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.18 (1.01\\u0026ndash;1.39)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eModel change (random -effects to fixed- effect model)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1.65 (1.59\\u0026ndash;1.70)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e91.94%\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"4. Discussion\",\"content\":\"\\u003cp\\u003eThis systematic review and meta-analysis study identified 15 studies for inclusion in the meta-analysis, of which only three had been conducted in South Africa. This highlights scarcity of high -quality targeted evidence evaluating the impact of interventions on VS in a South African setting. The results from the meta-analysis of 11 studies that were evaluated for effectiveness in improving VS demonstrate that the interventions were associated with improvement in VS. Although the magnitude of the pooled effect suggests modest improvement in VS, consistency of the findings across studies as indicated by low heterogeneity (I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;18.90%), suggests that these interventions provide some reliable benefit at the population level. Small relative improvements in VS are clinically meaningful in HIV care because they translate into reduced transmission risk, lower morbidity and progress toward UNAIDS 95-95-95 targets, which is particularly relevant in high-burden settings such as South Africa (45,46). Switching the model from random effects to fixed effect resulted in increased pooled estimate, which was persistently statistically significant, with higher heterogeneity, (I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;91.94%). This suggests that the larger studies reported higher effect than smaller studies, and that the findings remained robust and not sensitive to the choice of model.\\u003c/p\\u003e \\u003cp\\u003eThe modest increase in the pooled estimate and the loss of statistical significance that was observed when sensitivity analysis was restricted to studies done in South Africa, suggests that the excluded studies were either precise, large or had extreme effects which dominated the primary analysis. High heterogeneity could be due to the small number of studies that remained or it could be an indication of different populations, interventions or methodologies used across different settings.\\u003c/p\\u003e \\u003cp\\u003eSubgroup analysis revealed variation in effectiveness by intervention type. BSI showed the greatest improvement in VS with likelihood of improved VS higher among participants who received weekly SMS from the clinic nurse compared to those in the SoC arm. This underscores the importance of directly targeting adherence, treatment literacy, and self-management skills. Barriers related to medication adherence behaviors such as disruption of people\\u0026rsquo;s daily lives, forgetfulness, and treatment literacy play a central role in achieving sustained viral suppression. A study that was conducted in India has also reported an almost twice higher likelihood of viral suppression among adherence challenged participants who received behavioral adherence intervention than control participants (47, 48)\\u003c/p\\u003e \\u003cp\\u003eThe FSIs showed statistically significant improvement in VS, with moderate heterogeneity, I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;47.60%, indicating some variability in effect across the studies, potentially reflecting differences in type, amount, or duration of the financial support provided. FSIs involving monetary incentives conditional to clinic attendance showed the greatest effect (39,40). This suggests that addressing structural barriers such as transport cost, and economic constraints can facilitate effective use of ART; modest financial incentives or support mechanisms may reduce economic barriers to consistent ART access, particularly in resource-limited settings, although moderate heterogeneity indicates variability in implementation and context. A systematic review and meta-analysis study which evaluated the effects of monetary incentives on VS and adherence involving 13 RCTs, reported significant improvement on these two key treatment goals (49). However, another study that was conducted among adults on highly active antiretroviral therapy (HAART) has reported no significant association between social support and VS (50).\\u003c/p\\u003e \\u003cp\\u003eAlthough the pooled effect of PSIs did not demonstrate significant improvement on VS, one intervention involving training program for lay counsellors for attainment of MI skills showed statistically significant improvement in VS (36). PSIs may influence virologic outcomes indirectly through pathways such as mental health and social support which may require longer follow up to translate into measurable VS, as reflected by substantial heterogeneity across studies. A systematic review of studies conducted in the Unites States of America, and in a few countries in the sub-Saharan Africa (SSA) including South Africa, as well as Thailand found overall, small to moderate effects of PSIs on ART adherence, and VS among other outcomes (51). None of the SDIs showed a significant association with VS, which suggests that these interventions alone may not be sufficient to improve VS in the absence of complementary behavioral or structural components.\\u003c/p\\u003e \\u003cp\\u003eThe non-significant pooled effect of interventions on ART adherence highlights the complex and context dependent nature of adherence behaviors, and this coupled with the observed substantial heterogeneity (I\\u003csup\\u003e2\\u003c/sup\\u003e\\u0026thinsp;=\\u0026thinsp;70.03%) in the overall analysis suggests that intervention effectiveness is not uniform, and that aggregating diverse approaches may obscure benefits seen in specific intervention categories. The significant effect of BSIs aligns with existing evidence that interventions addressing practical adherence skills, motivation and routine building such as counselling, reminders and structural adherence support among ART patients are more likely to influence treatment taking behavior (52). These interventions may directly influence proximal determinants of adherence such as forgetfulness, treatment fatigue, thereby producing measurable improvements.\\u003c/p\\u003e\"},{\"header\":\"5. Strengths and limitations\",\"content\":\"\\u003cp\\u003eExpansion of the eligibility criteria following an empty review potentially introduced additional heterogeneity, contextually and methodologically. However, with ART delivery frameworks and the WHO aligned treatment guidelines shared across many African countries (53), the broader inclusion possibly allowed for a more comprehensive synthesis of the available evidence while maintaining conceptual consistency with the original objectives. Exclusion of studies which were not written in English, may have resulted in potentially relevant findings being overlooked. Additionally, this could result in missing out on diverse perspectives especially from countries in the Sub-Saharan region with HIV epidemiology similar to that of South Africa. Exclusion of the four studies from the meta-analysis due to providing insufficient reporting of quantitative outcome data required for effect size estimation, may have reduced the completeness of data synthesis and may have influenced the precision of the pooled effect estimates. This review, however, adhered to a registered protocol and followed the PRISMA guidelines to ensure transparency and reproducibility.\\u003c/p\\u003e\"},{\"header\":\"6. Conclusion\",\"content\":\"\\u003cp\\u003eIn summary, this meta-analysis provides evidence that ART-related interventions, particularly those incorporating behavioral, and financial support contribute to improved VS. These findings underscore the importance of addressing both individual-level behaviors and structural barriers in HIV treatment programmes, while highlighting the need for further high-quality studies to clarify the role of psychosocial and service-delivery interventions (SDIs). PSIs can be more effective when implemented as part of multi-component strategies rather than as standalone approaches. SDIs are likely to be more effective as maintenance strategies within stable populations or within broader multilevel adherence frameworks. These findings reinforce the need for targeted, risk-stratified approaches within ART programmes, whereby patients with unsuppressed viral loads receive intensified behavioral and structural support alongside routine service delivery adaptations.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eART\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eAntiretroviral therapy\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eBSIs\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eBehavioral support interventions\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eDSD\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eDifferentiated service delivery\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eFSIs\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eFinancial support interventions\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eHAART\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eHighly active antiretroviral therapy\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eHIV\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eHuman Immunodeficiency virus\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eJBI\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eJoanna Briggs Institute\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eKPs\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eKey populations\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eLE\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eLife expectancy\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eLMIC\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eLow-and-middle income countries\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eMSM\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eMen who have sex with men\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ePLWH\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003ePeople living with HIV\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ePRISMA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003ePreferred Reporting Items for Systematic Reviews and Meta-Analysis\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ePSIs\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003ePsychosocial support interventions\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ePWID\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003ePeople who inject drugs\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eRCT\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eRandomized controlled trial\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eRR\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eRisk ratio\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eRoB 2\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eCochrane\\u0026rsquo;s Risk of Bias 2.0\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eSDIs\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eSpecialized dispensing interventions\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eSoC\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eStandard of care\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eSSA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eSub Saharan Africa\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eSTIs\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eSexually transmitted infections\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eTB\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eTuberculosis\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eTGW\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eTransgender women\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eVR\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eViral rebound\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eVS\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eViral suppression\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003e\\u003cstrong\\u003e7. Ethical considerations\\u003c/strong\\u003e\\u003c/h2\\u003e\\n\\u003cp\\u003eThis study was ethically cleared by the research ethics committee of Sefako Makgatho health sciences university, SMUREC/H/31/2024:PG. As this study is a systematic review of previously published studies, no informed consent was required from primary participants\\u003c/p\\u003e\\n\\u003ch2\\u003e\\u003cstrong\\u003e8. Data Availability Statement\\u003c/strong\\u003e\\u003c/h2\\u003e\\n\\u003cp\\u003eThe data files generated and analysed during the current study are available from the corresponding author upon request\\u003c/p\\u003e\\n\\u003ch2\\u003e\\u003cstrong\\u003e9. Author Contributions\\u003c/strong\\u003e\\u003c/h2\\u003e\\n\\u003cp\\u003eLC: Conceptualization, Methodology, Data curation, Investigation, Formal Analysis, Writing–original draft. M.M.: \\u0026nbsp; Conceptualization, Methodology, Formal Analysis, Supervision,\\u0026nbsp;Validation,\\u0026nbsp;Writing – review \\u0026amp; editing. OO: Methodology, Formal Analysis, Supervision, Validation,\\u0026nbsp;Writing–review \\u0026amp; editing. All authors have read and agreed to the published version of the manuscript\\u003c/p\\u003e\\n\\u003ch2\\u003e\\u003cstrong\\u003e10.\\u0026nbsp;Funding\\u003c/strong\\u003e\\u003c/h2\\u003e\\n\\u003cp\\u003eThis research received no external funding\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch2\\u003e\\u003cstrong\\u003e11.\\u0026nbsp;Conflict of Interest\\u003c/strong\\u003e\\u003c/h2\\u003e\\n\\u003cp\\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\\u003c/p\\u003e\\n\\u003ch2\\u003e\\u003cstrong\\u003e12.\\u0026nbsp;Acknowledgments\\u003c/strong\\u003e\\u003c/h2\\u003e\\n\\u003cp\\u003eThe authors would like to thank Mr. Lindokuhle Ndlazi for providing his independent validation during the article selection process.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003e1. Joint United Nations Programme on HIV/AIDS. Global HIV statistics.2025 https://www.unaids.org/en/resources/fact-sheet. [Accessed on December 15,2025]\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e2. World Health Organization. African region. HIV/AIDS. https://www.afro.who.int/health-topics/hivaids. [Accessed on December 15,2025\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e3. Jarvis JN, Ehrenkranz P, Lawrence DS, Keene CM, Reid MJ, Katz IT, Shodell D, P\\u0026eacute;rez-Casas C, Mupeli K, Sivile S, Couto AM. Reducing HIV incidence and mortality: two sides of the same coin in the approach to ending AIDS. The Lancet HIV. 2026 Mar 1;13(3):e207-12.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e4. Tanser F, de Oliveira T, Maheu-Giroux M, B\\u0026auml;rnighausen T. Concentrated HIV subepidemics in generalized epidemic settings. Current Opinion in HIV and AIDS. 2014 Mar 1;9(2):115\\u0026thinsp;\\u0026minus;\\u0026thinsp;25.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e5. Robbins RN, Spector AY, Mellins CA, Remien RH. Optimizing ART adherence: update for HIV treatment and prevention. Current Hiv/Aids Reports. 2014 Dec;11(4):423\\u0026thinsp;\\u0026minus;\\u0026thinsp;33.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e6. Religioni U, Barrios-Rodr\\u0026iacute;guez R, Requena P, Borowska M, Ostrowski J. Enhancing therapy adherence: impact on clinical outcomes, healthcare costs, and patient quality of life. Medicina. 2025 Jan 17;61(1):153.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e7. Joint United Nations Programme on HIV/AIDS. People\\u0026rsquo;s Republic of China unveils US\\u003cspan\\u003e$\\u003c/span\\u003e 3.49\\u0026nbsp;million HIV prevention support for South Africa, facilitated by UNAIDS.[Press release]. GENEVA/JOHANNESBURG, 2025 November 20. https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2025/november/20251121_China_prevention_SA. [Accessed on January15,2026]\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e8. Human Sciences Research Council. New HIV survey highlights progress and ongoing disparities in South Africa\\u0026rsquo;s HIV epidemic.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e9. Murewanhema G, Musuka G, Moyo P, Moyo E, Dzinamarira T. HIV and adolescent girls and young women in sub-Saharan Africa: A call for expedited action to reduce new infections. IJID regions. 2022 Dec 1;5:30\\u0026thinsp;\\u0026minus;\\u0026thinsp;2.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e10. Johnson LF, May MT, Dorrington RE, Cornell M, Boulle A, Egger M, Davies MA. Estimating the impact of antiretroviral treatment on adult mortality trends in South Africa: A mathematical modelling study. PLoS medicine. 2017 Dec 12;14(12):e1002468.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e11. van Wyk BE, Davids LA. Challenges to HIV treatment adherence amongst adolescents in a low socio-economic setting in Cape Town. Southern African Journal of HIV Medicine. 2019;20(1):1\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e12. World Health Organization. Status and challenges of ART adherence in SA: How the UN can help. 2015 0ct 02. https://www.afro.who.int/countries/south-africa/news/status-and-challenges-art-adherence-sa-how-un-can-help. [Accessed January16,2026]\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e13. Bondarchuk CP, Mlandu N, Adams T, de Vries E. Predictors of low antiretroviral adherence at an urban South African clinic: A mixed-methods study. Southern African Journal of HIV Medicine. 2022 Feb 10;23(1):1343.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e14. Kaswa R, De Villiers MR. The effect of substance uses on antiretroviral treatment adherence in primary health care. South African Family Practice. 2023 Mar 30;65(1):5660.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e15. Potsane P. Factors associated with patients defaulting on HIV treatment at Helen Joseph Hospital, Gauteng province, South Africa. African Journal of AIDS Research. 2023 Apr 3;22(2):85\\u0026ndash;91.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e16. Human Sciences Research Council. Turning the tide-SA HIV survey shows encouraging trends in prevalence, prevention and treatment. 2024 July 2. https://hsrc.ac.za/press-releases/sabssm/turning-the-tide-sa-hiv-survey-shows-encouraging-trends-in-prevalence-prevention-and-treatment/. [Accessed on January 16,2026]\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e17. Buthelezi SS. 2023 ART clinical guidelines for the management of HIV in adults, pregnancy and breastfeeding, adolescents, children, infants and neonates. SA Pharmaceutical Journal. 2023 Dec 1;90(6):35\\u0026ndash;50.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e18. Opoku S, Sakyi SA, Ayisi-Boateng NK, Enimil AK, Senu E, Ansah RO, Aning BD, Ojuang DA, Wekesa DN, Ahmed FO, Okeke CB. Factors associated with viral suppression and rebound among adult HIV patients on treatment: a retrospective study in Ghana. AIDS Research and Therapy. 2022 May 25;19(1):21.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e19. Kirabira A, Bukenya J, Ssenkusu J, Ssekamatte NK, Tumwesigye NM, Kiwanuka N. PREDICTORS OF VIRAL REBOUND AMONG ADOLESCENTS AT AN URBAN CLINIC IN KAMPALA USING REPEATED EVENTS SURVIVAL ANALYSIS. medRxiv. 2024 Jul 29:2024-07.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e20. Mpolya EA. A prospective study for predictors of HIV viral load rebound in an HIV hyperendemic rural population of KwaZulu-Natal, South Africa. PAMJ-One Health. 2023 Aug 2;11(13).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e21. Azia IN, Mukumbang FC, Van Wyk B. Barriers to adherence to antiretroviral treatment in a regional hospital in Vredenburg, Western Cape, South Africa. Southern African journal of HIV medicine. 2016 Jan 1;17(1):1\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e22. Magura J, Nhari SR, Nzimakwe TI. Barriers to ART adherence in sub-Saharan Africa: a scoping review toward achieving UNAIDS 95-95-95 targets. Frontiers in Public Health. 2025 Jun 10;13:1609743.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e23. Ukoaka BM, Ugwuanyi EA, Ukueku KO, Ajah KU, Udam NG, Daniel FM, Wali TA, Gbuchie MA. Digital tools for improving antiretroviral adherence among people living with HIV in Africa. 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BMJ open. 2025 Mar 1;15(3):e087369.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e27. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng H-Y, Corbett MS, Eldridge SM, Hern\\u0026aacute;n MA, Hopewell S, Hr\\u0026oacute;bjartsson A, Junqueira DR, J\\u0026uuml;ni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT. RoB 2: a revised tool for assessing risk of bias in randomised trials. \\u003cem\\u003eBMJ\\u003c/em\\u003e 2019; \\u003cb\\u003e366\\u003c/b\\u003e: l4898.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e28. Joanna Briggs Institute. Checklist for cohort studies: Critical Appraisal tools for use in JBI Systematic Reviews: Joanna Briggs Institute; 2020 [Internet]. https://jbi.global/sites/default/files/2020-08/Checklist_for_Cohort_Studies.pdf. 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AIDS Research and Therapy. 2025 Mar 29;22(1):39.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"Sefako Makgatho Health Sciences University\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"facilitating/improving viral suppression, enhancing viral suppression, reducing episodes of viral rebound, resuppression\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9574334/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9574334/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground: \\u003c/strong\\u003eA wide range of\\u003cstrong\\u003e \\u003c/strong\\u003einterventions have been implemented to improve viral suppression (VS) among patients on antiretroviral therapy (ART). While many of primary studies report positive effects on VS, results vary considerably across intervention type, populations and health systems context\\u003cstrong\\u003e. \\u003c/strong\\u003eThis systematic review and meta-analysis study conducted a comprehensive search for evidence of effective interventions to improve VS among adult patients who were on antiretroviral therapy (ART) in Africa.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods: \\u003c/strong\\u003eSearches were conducted in Pubmed and EbscoHost databases (Medline and CINHAL) in July 2025. Two reviewers independently screened study titles, abstracts, and full-texts and found 15 studies which met the study inclusion criteria. Quality and risk of bias were assessed using Cochrane’s Risk of Bias 2.0 (RoB 2) and Joanna Briggs Institute (JBI) checklist. Relative risks (RR) and the 95% CIs were calculated to quantify the magnitude of the effect of interventions on viral suppression and ART adherence using STATA17. The I-squared statistic (I\\u003csup\\u003e2\\u003c/sup\\u003e) was used to assess the presence of heterogeneity.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults :\\u003c/strong\\u003e Behavioral support and financial support interventions were associated with statistically significant increased likelihood of improved VS, respectively, (RR=1.18, 95% CI: 1.01-1.39), and RR= 1.05 (95% CI:1.01-1.10),I\\u003csup\\u003e2\\u003c/sup\\u003e=47.60%. The behavioural support intervention was also significantly\\u0026nbsp; associated with high ART adherence (RR=1.24, 95% CI:1.06-1.44).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions: \\u003c/strong\\u003eThese findings\\u003cstrong\\u003e \\u003c/strong\\u003eunderscore the importance of addressing structural barriers and \\u0026nbsp;individual behaviors in HIV treatment programmes. Furthermore, they highlight the need for studies that will clarify the role of psychosocial and service-delivery interventions for improving VS.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSystematic review registration\\u003c/strong\\u003e: CRD42024532244\\u003c/p\\u003e\\n\\u003cp\\u003ehttps://pmc.ncbi.nlm.nih.gov/articles/PMC11927478/\\u003c/p\\u003e\",\"manuscriptTitle\":\"Interventions to improve viral suppression in antiretroviral therapy patients in Africa: A Systematic Review and Meta analysis\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-05-04 10:21:24\",\"doi\":\"10.21203/rs.3.rs-9574334/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"2f81e839-6f8e-4d06-a218-471eb5286ce7\",\"owner\":[],\"postedDate\":\"May 4th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":67303164,\"name\":\"Infectious Diseases\"}],\"tags\":[],\"updatedAt\":\"2026-05-04T10:21:24+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-05-04 10:21:24\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9574334\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9574334\",\"identity\":\"rs-9574334\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}