Table 3.

Identification of recurrent or salient themes across the selected studies based on the realist logic

Study	Intervention modalities	Actors	Context	Mechanism	Outcome
Decroo et al. (2011) [53]	- A group representative visits the nearest health facility to collect medicines for the group. - Group members could still visit the health centre at any other time - A group meeting is held in the community before each clinic visit, and the designated group leader counts each members’ pills - The group representative meets with a clinician who prescribes ART and prophylactic drugs for each group member.	- Stable patients on ART - Adherence counsellor or clinician	- Poverty among ART patients - Perceived stigmatisation of patients when theyattend clinics - Treatments guidelines allow for one clinical consultation every 6 months and monthly supplies of medication.	- Building and reinforcing social networks and peer support - Encouraging greater patient responsibility	- Decrease the financial and economic/social costs of their treatment - Greater responsibility for the management of their own health
Decroo et al. (2014) [52]	- Community ART groups (CAG) - Peer support groups involved in community ART distribution - Mutual psychosocial support	- Stable patients on ART - Group of CAG members	- Difference psycho-social and biomedical characteristics than patients - Difference in adherence profile of patients in the CAG model	None identifieda	- Mortality and loss to follow-up rates were better for patients in the CAG group than the clinic cohort - Retention in care rates with time was also improved.
Dudhai & Kagee [50]	- Facility-based antiretroviral adherence club	- Stable patients on ART	- Consistent and timely delivery of medication (failure) - Management of logistics by the host facility - Communication challenges between the host facility and the Chronic Dispensing Unit Staffing dynamics - need for more staff to run more clubs	- Cohesion among club members - ART users view themselves as active rather than passive participants in their care.	- Decongest the clinics so we have more time to spend with the sick patients or the new patients. - Shorter waiting time - Avoids financial loss on the part of the patient
Grimsrud et al. (2015) [30]	- Community-based antiretroviral adherence club intervention - Support ART maintenance for groups of stable patients in a community health worker-facilitated model with peer-support and increased patient self-management - Shifting the service away from health facilities to be community-based - Most CACs met five times per year	- Stable ART patients - Groups of 25–30 - Community health worker - A professional nurse was assigned as the CAC nurse rotating on a monthly basis.	- Limited resources within the community venue and distance to CHC for supplies - Policies regarding dispensing and distribution - Ensuring access to a clean and appropriate community-based facility - Limited resources within the community venue and distance to CHC for supplies	None identifieda	- Better retention in care - Fewer people lost to follow-up and less attrition from the care programme
Khabala et al. (2015) [60]	- Medication Adherence Clubs - MACs are nurse-facilitated groups of 25–35 stable hypertension, diabetes mellitus and HIV patients who meet quarterly to (i) confirm their clinical stability, (ii) have a short health talk and (iii) receive pre-packed medications. - Routine patient follow-up with clinical officers occurs yearly when a patient develops complications or no longer meets the inclusion criteria.	- HIV and non-communicable disease patients - Professional nurse	None identifieda	- Patient satisfaction	- An efficacious method of reducing clinicians’ workload - It also demonstrates a low loss to follow-up
Luque-Fernandez et al. (2013) [29]	Facility-based antiretroviral adherence club - Facilitated by non-clinical staff (counsellors) - Groups of 15 to 30 patients are formed and convene at the clinic during quiet times - Medicines are pre-packaged for each participant and brought to the group by a counsellor who weighs the patients and administers a symptom-based general health assessment. - Any patients reporting symptoms suggestive of illness, adverse drug effects or who have weight loss are referred to the clinic to be assessed by a nurse. - The counsellor or experienced patients lead short group discussions on health issues - A draw blood for viral load and CD4 count testing.	- Stable patients on ART - Non-clinical staff (counsellors) - Professional nurse	None identifieda	- Group dynamic itself may be an important contributor as was historically motivated	- Administrative efficiency and decongestion of services are key aspects of the model - Improved retention in care might result due to the removal of these and other structural barriers to care - Virologic rebound was lower in the club model
Rasschaert et al. (2014a) [27]	- Community ART groups (CAG) - Based on the principles of self-management. - Patients rotate to pick up medication supplies for the rest of the group on a monthly basis - Each group elects a group leader, who functions as a spokesperson for the group. - The group members meet regularly in the community, perform monthly pill counts and offer mutual adherence support. - Lay counsellors, assist in forming and monitoring the groups in health facilities and the community	- Stable patients on ART - Group of CAG members - Involvement of other organisations likes MSF - Involvement of the Ministry of Health - Lay counsellors	- Progressive ministry of health involvement and integration of activities in existing health services - Flexibility to adapt to changing patients’ needs over time - Community participation - CAG model is well accepted by all stakeholders - Changed mindset of all stakeholders concerning the new health care approach - Continuous supervision, training and coaching sessions for patients and health staff - Low educational levels of most patients - Chronic shortage of staff	- Self-management and patient empowerment - Mutual adherence support - Increased assurance of timely access to ART - Motivation of care staff - Strong social links and networks between members	- Decreased workload and better monitoring of patients - Better general well-being - Less loss to follow-up and deaths - Improved adherence to treatment - Increased HIV awareness - Increased uptake of HIV testing, and a reduction of stigma
Rasschaert et al. (2014b) [54]	- Counsellor key role in forming and monitoring groups - GAC members participate in HIV-related activities in clinics and community - Group established CAG entry requirements - Flexible application of medical CAG eligibility criteria	- MSF employed counsellors - Stable patients on ART - Group of CAG members	- Permanent presence of counsellors in clinics - Resources for training and meetings - Consistent drug supply - Buy-in from the Ministry of Health - Problems with group formation, rotation system and relationships in groups	- Empowerment of patients - Mutual adherence support - Social control through ‘Code of Conduct.’ - Bonding between CAG members - Trust relationship - Patients are actively involved in their health decision-making - Problem-solving skills	- Better HIV awareness - Improved quality of care provided as supervision is in place - Decreased stigma - Improvement in the quality of health for patients - Better access to drug refills contributed to improved retention on ART.
Rasschaert et al. (2014c) [55]	- Groups comprise up to six stable patients on ART - Monthly, a group member is appointed to collect the drugs on behalf of the group and reports on and receives medical consultations for the group members. - Counsellors, sensitise patients to join groups and monitor the group activities.	- Stable patients on ART - Group of CAG members - MSF employed counsellors	- Weak healthcare system - Shortage in health staff - Lack of infrastructure - Discrimination and social exclusion when monthly attending the clinic. - Cultural beliefs that HIV is caused by spiritual spells and can only be managed by traditional healers - CAG intervention widely accepted among stakeholders	- Patients’ active role in health care - Social control and group rules - Psycho-social support - Understand the importance of taking medication - Very strong bond and network between the members.	- Reduced workload and improved quality of care in clinics - Better health outcomes - New identity of CAG members in group, clinic and community - The less frequent clinic visits per individual patient reduce the time and cost investment significantly - Better adherence to medication
Rich et al. (2012) [57]	- Patients qualifying for ART were given the option of entering a group of 12–24 persons for ongoing patient education and support. - Group enrollment consisted of a 3-h educational session and four individual visits before the initiation of ART. - After ART initiation, groups would attend routinely scheduled visits on the same day and meet for ongoing patient education and social support. - Routine visits occurred monthly for the first 10 months and then bi-monthly afterwards	- Patients qualifying for ART - Trained community health workers, also known as an “accompagnateurs,”	- Targeted support provided to health centres to ensure adequate staffing and retention of trained nurses, plus weekly physician supervision visits. - Trained CHWs, also known as an “accompagnateurs,” performed daily home visits. - Each patient received a monthly food package valued at the US $30 - Housing assistance, employment training and school fee support for patients and families in grave socioeconomic circumstances.	None identifieda	- Good retention in care rates is retaining people in care at 2 years with very low rates of loss to follow-up and death.
Vandendyck et al. (2015) [56]	Community adherence group - PLWHA stable on ART was invited to constitute a CAG - CAG members meet monthly in the community. - During the meeting, they verify each other’s pill count (adherence) and choose a representative to go to the health facility. - At the health facility, the group representative has a consultation on behalf of the rest of the group members. - Then the representative returns to the community to distribute ART to the fellow group members	- PLWHA stable on ART - Community health workers	- Support from the village head - Separation of monthly ART refills from clinical assessments - Need for a reliable drug supply system to ensure access to ART - Availability of appropriate number of community health workers and lay counsellors to support the formation, training and monitoring of CAGs - Need for clear mechanisms to trigger support or referral back to clinic care to ensure patients and groups in need receive appropriate care - Availability of a simplified monitoring system to avoid increased administrative workload	- Being together, living in the same situation, bring the CAG to form a network of peers - Patients were empowered to take responsibility and to support each other. - Induced peer support, which enhanced adherence - Socio-economic support and empowered members to deal with stigma - Feeling of relief and comfort - Empowerment resulted from a new role for patients	- Village health workers confirmed increased openness about HIV in their community - Community leaders added that CAG members promoted health-seeking behaviour to community members - Clinicians reported a workload reduction. - Better retention in care within the first year of CAG membership. - Reduced time, effort and money spent to get a monthly ART refill
Venables et al. (2016) [59]	- Medication Adherence Clubs provide a medication refill system for stable HIV, diabetes and hypertensive patients. - Medications are pre-packed and labelled by the pharmacy - MACs are made of 10–30 stable hypertension, diabetes mellitus and HIV patients who meet quarterly to (i) confirm their clinical stability, (ii) have a short health talk and (iii) receive pre-packed medications. - Fast-track appointments - Routine patient follow-up with clinical officers occurs yearly when a patient develops complications or no longer meets the inclusion criteria.	- Stable HIV, diabetes and hypertensive patients - Non-medical health educators	- High prevalence of HIV, diabetes and hypertension - Support from a non-government organisation - Population living in informal settlements	- Patient satisfaction - Social support (mutual adherence support) - Acceptability related to advantages, - Empowerment	- MACs reduce waiting times and prevented unnecessary queues - MACs reduce stigma for HIV-positive patients

MAC Medication Adherence Club, CAG community ART groups, CHW community health worker

^aNo phrase corresponded to the definition of a mechanism as outlined in the coding framework