Understanding implementation barriers in the national scale-up of differentiated ART delivery in Uganda

Henry Zakumumpa,Cordelia Katureebe,Neil Spicer,Joseph Rujumba,Japheth Kwiringira

doi:10.1186/s12913-020-5069-y

Abstract

BackgroundAlthough Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)‘s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perspectives on barriers to implementation of Differentiated ART service delivery in Uganda.MethodsWe employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context.ResultsOur data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Context: Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups.ConclusionThis is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

Highlights

Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)‘s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes
Individual fears of involuntary disclosure of HIV status to peers was frequently cited as an impediment to enrollment in DSD models across our focus groups with patients and interviews with health workers
DSD confers several advantages to patients such as savings in time spent at facilities and a reduction in transport costs incurred in seeking care, patients have other considerations which we have found to be contrary to our expectations’ ART clinic in-charge, PNFP-01

Summary

Introduction

Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)‘s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. Due to the widespread overcrowding and the resourceconstrained operational contexts of HIV clinics in SSA, innovations in HIV service delivery approaches have become imperative [1,2,3,4,5,6,7]. In 2016, DSD was endorsed by the World Health Organization (WHO) and leading global HIV donors such as Presidents’ Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) as a novel evidence-informed HIV service delivery approach that relieves pressure on over-burdened health systems in SSA [2]. Duncombe and colleagues [7] posit that these innovative HIV service delivery alternatives constitute elements that entail a reduction in service intensity and frequency for stable patients, task shifting to non-clinical health worker cadre and changes in service location (such as coopting community-based platforms)

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