Abstract
Differentiated service delivery (DSD) offers benefits to people living with HIV (improved access, peer support), and the health system (clinic decongestion, efficient service delivery). ART clubs, 15-30 clients who usually meet within the community, are one of the most common DSD options. However, evidence about the quality of care (QoC) delivered in ART clubs is still limited. We conducted a concurrent triangulation mixed-methods study as part of the Test & Treat project in northwest Tanzania. We surveyed QoC among stable clients and health care workers (HCW) comparing between clinics and clubs. Using a Donabedian framework we structured the analysis into three levels of assessment: structure (staff, equipment, supplies, venue), processes (time-spent, screenings, information, HCW-attitude), and outcomes (viral load, CD4 count, retention, self-worth). We surveyed 629 clients (40% in club) and conducted eight focus group discussions, while 24 HCW (25% in club) were surveyed and 22 individual interviews were conducted. Quantitative results revealed that in terms of structure, clubs fared better than clinics except for perceived adequacy of service delivery venue (94.4% vs 50.0%, p = 0.013). For processes, time spent receiving care was significantly more in clinics than clubs (119.9 vs 49.9 minutes). Regarding outcomes, retention was higher in the clubs (97.6% vs 100%), while the proportion of clients with recent viral load <50 copies/ml was higher in clinics (100% vs 94.4%). Qualitative results indicated that quality care was perceived similarly among clients in clinics and clubs but for different reasons. Clinics were generally perceived as places with expertise and clubs as efficient places with peer support and empathy. In describing QoC, HCW emphasized structure-related attributes while clients focused on processes. Outcomes-related themes such as improved client health status, self-worth, and confidentiality were similarly perceived across clients and HCW. We found better structure and process of care in clubs than clinics with comparable outcomes. While QoC was perceived similarly in clinics and clubs, its meaning was understood differently between clients. DSD catered to the individual needs of clients, either technical care in the clinic or proximate and social care in the club. Our findings highlight that both clinic and DSD care are required as many elements of QoC were individually perceived.
Highlights
Quality of care is at the heart of the differentiated care strategy currently endorsed by WHO for HIV programs
Differentiated service delivery (DSD) catered to the individual needs of clients, either technical care in the clinic or proximate and social care in the club
Our findings highlight that both clinic and DSD care are required as many elements of quality of care (QoC) were individually perceived
Summary
Quality of care is at the heart of the differentiated care strategy currently endorsed by WHO for HIV programs. Community health workers (CHW) have been involved in various HIV interventions before DSD roll-out [3–6] Their role in DSD varies depending on whether they are supporting or coordinating the specific intervention. They assist other HCW to provide adherence counseling, distribute pre-packaged antiretrovirals (ARVs), client tracking, documentation, and home visits. As coordinators, they are responsible for facilitating antiretroviral therapy (ART) “clubs” (i.e., small groups of 15 to 30 stable clients who meet at the clinic or community), screening and identifying symptoms of common opportunistic infections e.g., tuberculosis (TB) for upward referral, following up clients who miss appointments, collecting and distributing ARVs to clients. Evidence about the quality of care (QoC) delivered in ART clubs is still limited
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