IMPAACT 2016: Operationalizing HIV Intervention Adaptations to Inform the Science and Outcomes of Implementation
Uptake of evidence-based interventions for adolescents and young adults living with HIV (AYA-LWH) in sub-Saharan Africa (SSA) is complex, and cultural differences necessitate local adaptations to enhance effective implementation. Few models exist toguide intervention tailoring, yet operationalizing strategies is critical to inform science and implementation outcomes, namely acceptability, appropriateness, feasibility, fidelity, and sustainability. This paper describes operationalizing the ADAPT-ITT framework appliedto a manualized trauma-informed cognitive behavioral therapy (TI-CBT) intervention addressingmental and sexual health for AYA-LWHin SSA in preparation for a randomized controlled trial (RCT).Methods: Phase 1 of the RCT focused on operationalizing ADAPT-ITT steps 3–7 totailor the intervention for use in eight sites across Botswana, Malawi, South Africa,and Zimbabwe. Well-defined processes were developed to supplement the generalguidelines for each step to provide clear, consistent direction on how to prepare andconduct each step, including documenting, assessing, and determining adaptations,while maintaining intervention fidelity. The processes provided efficient standardizedstep-by-step progression designed for future replication. All sites participated in Phase 1using the created tools and strategies to translate and present the TI-CBT to community stakeholders for feedback informing local adaptations.Results: The research team developed and operationalized materials guidingadaptation. A translation review process verified local adaptability, maintained coreconcepts, and revealed differing interpretations of words, idioms, and culturallyacceptable activities. Strategically designed tools comprised of feedback andtranslation verification forms resulted in meticulous management of adaptations. Robustcollaborations between investigators, research managers, site personnel, and topicalexperts maximized multidisciplinary expertise, resulting in 10–15 personnel per sitefacilitating, collecting, assessing, and integrating local feedback. Processes and toolsoperationalized in steps 3–7 effectively addressed implementation outcomes duringcommunity engagements (n = 108), focus groups (n = 5–8 AYA-LWH and caregiversper group), and strategic training of youth leaders.Discussion: This paper offers a novel generalizable approach using well-definedprocesses to guide intervention adaptation building on the ADAPT-ITT framework.The processes strengthen the science of implementation and provide much-neededspecificity in adaptation steps to optimize and sustain real-world impact and helpresearchers and community stakeholders maximize existing infrastructure, culture, andresources to inform implementation strategies..
