Commonality and co-occurrence of discrete strategies within implementation strategy bundles: findings from the Living...

HIV services and innovations are delivered through implementation strategy bundles that are often complex, comprising numerous discrete strategies. Systematically characterizing the use patterns of discrete strategies may inform strategy prioritization and selection to optimize service delivery. We used the Living Database of HIV Implementation Science (LIVE) to describe the commonality and co-occurrence of discrete strategies within multi-component strategy bundles in published HIV implementation studies from low- and middle-income countries.

The LIVE systematic review identified studies from PubMed, Embase, and CINAHL, and included HIV implementation studies that reported ≥ 1 HIV care cascade outcome, were conducted in low- and middle-income countries, and were published between January 1, 2014, and August 27, 2021. Discrete strategies were inductively specified (e.g., actor, action, action target) and classified into 5 categories consolidated from 2 strategy taxonomies, Effective Practice and Organisation of Care and Expert Recommendations for Implementing Change. Network analysis was conducted to describe the co-occurrence of discrete strategies within study arm strategy bundles.

A total of 4,253 discrete implementation strategies were identified from 868 study arms across 485 individual studies, with a median of four reported strategies per study arm (range: 1-21). The most common strategies used were 'providing education on a health innovation, service, or behavior' (60%; 520/868) and 'training to learn a new skill' (30%; 260/868) under the 'Capacity Building and Support' category. These were also the most commonly co-occurring strategies within strategy bundles (degree centrality: 4,894 and 3,488, respectively) and were most often present to allow other strategies to co-occur in bundles (betweenness centrality: 3,526.3 and 1,647.0, respectively). Several other 'Capacity Building and Support' or 'Health Service Delivery' categories were common and central. Strategies related to 'Financial Arrangement,' 'Governance,' and 'Implementation Process' were infrequently reported and/or underutilized.

Capacity building approaches and changes to health service delivery are common in published HIV implementation strategy bundles. Future implementation studies should evaluate bundles of a more diverse range of strategies that target barriers at organization and health system levels.