Optimizing Differentiated HIV Treatment Models in Urban Zimbabwe: Assessing Patient Preferences Using a Discrete Choice Experiment

Michael Strauss,Matthew R Lamb,Martin Msukwa,Innocent Chingombe,Munyaradzi Mapingure,Tsitsi Apollo,Godfrey Musuka,Rodrigo Boccanera,Tsitsi B Masvawure,Jennifer M Zech,Miriam Rabkin,Joanne E Mantell,Gavin George,Clorata Gwanzura

doi:10.1007/s10461-020-02994-z

Abstract

Differentiated service delivery holds great promise for streamlining the delivery of health services for HIV. This study used a discrete choice experiment to assess preferences for differentiated HIV treatment delivery model characteristics among 500 virally suppressed adults on antiretroviral therapy in Harare, Zimbabwe. Treatment model characteristics included location, consultation type, healthcare worker cadre, operation times, visit frequency and duration, and cost. A mixed effects logit model was used for parameter estimates to identify potential preference heterogeneity among participants, and interaction effects were estimated for sex and age as potential sources of divergence in preferences. Results indicated that participants preferred health facility-based services, less frequent visits, individual consultations, shorter waiting times, lower cost and, delivered by respectful and understanding healthcare workers. Some preference heterogeneity was found, particularly for location of service delivery and group vs. individual models; however, this was not fully explained by sex and age characteristics of participants. In urban areas, facility-based models, such as the Fast Track model requiring less frequent clinic visits, are likely to better align with patient preferences than some of the other community-based or group models that have been implemented. As Zimbabwe scales up differentiated treatment models for stable patients, a clear understanding of patient preferences can help in designing services that will ensure optimal utilization and improve the efficiency of service delivery.

Highlights

Zimbabwe’s Ministry of Health and Child Care (MoHCC) has made significant progress in scaling up HIV services
Participants did not prefer to collect their medication from a community-based collection point compared to a clinic close to home, nor did they prefer a home-based delivery model compared to a clinic close to home
Our analysis found some evidence of preference heterogeneity, the study found that on the whole, there was a significant preference for clinic-based models compared to community- or home-based models—a finding consistent with a recent discrete choice experiment (DCE) from Zambia which found that urban populations were more likely to prefer clinic-based models to models offered in the community [24]

Summary

Introduction

Zimbabwe’s Ministry of Health and Child Care (MoHCC) has made significant progress in scaling up HIV services. In the context of Zimbabwe’s limited resources and strained health system, the MoHCC launched a differentiated service delivery (DSD) strategy for HIV, in which stable adult patients on ART were moved to less-intensive treatment models [2]. Zimbabwe has been an early adopter of differentiated ART (DART), which is a global strategy endorsed by the World Health Organization (WHO) and implemented by countries around the world [3, 4]. DART moves away from a “one size fits all” to a patient-centered approach, enabling stable patients on ART to opt into models with fewer and faster visits to health facilities or community-based services [5]. By putting patients at the center of ART delivery and tailoring variables such as visit frequency, visit location and health care worker (HCW) cadre, DART can enhance the quality and efficiency of health services, as well as improve both patient satisfaction and alleviate the burden on the health system [6, 7]

Methods

Results

Discussion

Conclusion