Objective This study applies a realist synthesis approach to analyze the context-mechanism-outcome (CMO) configurations of psychological resilience interventions for people living with HIV/AIDS. This study aims to explore the applicability and activation pathways of interventions across different contexts, and to construct an actionable theoretical framework to guide personalized intervention design. Methods According to the RAMESES reporting guidelines, a five-stage realist synthesis approach was adopted. The PubMed, Embase, Cochrane Library, Web of Science, CINAHL, CBM, WanFang Data, VIP, and CNKI databases were electronically searched from the inception to July 1, 2025. Two researchers independently screened studies and assessed quality by relevance and rigor. Intervention elements were extracted to build and refine CMO configurations through stakeholder feedback, forming the final theory. Results A total of 32 studies were included. Four key intervention mechanisms were identified: cognitive-behavioral approaches, social support, self-efficacy enhancement, and strength-based positive psychology. The findings highlight that intervention effectiveness depends on context alignment and mechanism activation. Single mechanisms may be less effective in resource-limited or high-stress settings. Conclusion Psychological resilience interventions for HIV/AIDS patients should be context-specific, combining mechanisms in tailored ways to improve relevance and impact
