Differentiated Service Delivery Models Research Articles

Availability and readiness of public health facilities to provide differentiated service delivery models for HIV treatment in Zambia: implications for better treatment outcomes

BackgroundThere is persistent pressure on countries with a high burden of HIV infection to reach desired targets for HIV treatment outcomes. This has led to moving from the “one-size-fits-all” model to differentiated service delivery (DSD) models, which are meant to be more patient-centered and efficient but without compromising on the quality of patient care. However, for DSD models to be efficient, facilities should have indicators of HIV services available and ready to provide the DSD models. We aimed to assess the availability of HIV service indicators and the readiness of facilities to provide DSD models for HIV treatment in selected public health facilities in Zambia.MethodsWe conducted a nationwide cross-sectional survey among public health facilities in Zambia that provide antiretroviral therapy (ART) services. We used an interviewer-administered questionnaire based on a World Health Organization (WHO) Service Availability Readiness Assessment (SARA) tool to assess the availability of HIV service indicators and the readiness of facilities to implement DSD models for HIV treatment. Availability and readiness were considered latent constructs, and therefore, we used structural equation modeling (SEM) to determine the correlations between them and their respective indicators.ResultsOf 60 public health ART facilities, the overall availability of HIV service indicators was 80.0% (48/60), and readiness to provide the DSD models was 81.7% (48/60). However, only 48 and 39% of the facilities had all indicators of availability and readiness, respectively. Retention in care for HIV multidisciplinary teams was more likely to occur in urban areas than in rural areas. SEM showed that the standardized estimate between availability and readiness was significantly and positively correlated (r = 0.73, p < 0.0001). In addition, both availability and readiness were significantly and positively correlated with most of their respective indicators.ConclusionAlthough most facilities had available HIV service indicators and were ready to provide DSD models, most facilities did not have all indicators of availability and readiness. In addition, there were differences between rural and urban facilities in some indicators. There is a need for persistent and heightened efforts meant to implement DSD in HIV treatment, especially in rural areas to accelerate reaching the desired HIV treatment outcomes.

Association between differentiated HIV care delivery model and low-level viremia among people living with HIV in Rwanda

BackgroundLow-level viremia (LLV) (HIV-RNA 51–999 copies/mL) is associated with increased risk of non viral load suppression (HIV-RNA ≥ 1000 copies/mL). We assessed the association between differentiated service delivery model (DSDM) and LLV among people living with HIV (PLHIV) in Rwanda.MethodsWe conducted a retrospective cohort analysis using routinely collected data of adults living with HIV from 28-healthcare facilities in Rwanda before and after the introduction of DSDM. Under DSDM, PLHIV initiated treatment within seven days of HIV diagnosis and medication pick-up up to six months for those with sustained viral load suppression suppression. Proportions of LLV at 6,12 and 18 months were quantified. Multivariable log binomial regression models were used to assess the effect of DSDM on LLV. To handle missing data, multiple imputations was performed.ResultsOf 976 people living with HIV, 645(66.0%) were female and 463(47.4%) initiated treatment during DSDM. The median age was 37 (interquartile range: 32–43) years. LLV was 7.4%, 6.6% and 5.4%, at 6,12 and 18 months, respectively. Compared to those who initiated treatment before DSDM, starting treatment during DSDM increased six-month LLV [adjusted risk ratio (aRR) = 2.8: 95%CI (1.15–6.91)] but not at 12 [aRR = 2.3: 95%CI (0.93–5.75)] and 18 months [aRR = 0.3: 95%CI (0.09–1.20)]. Using imputed datasets, the association between DSDM and LLV persisted.ConclusionsDSDM was associated with increased risk of LLV at 6-months. possibly due to the minimal amount of time PLHIV had in pondering and accepting the HIV diagnosis. Continued support is needed among people receiving early antiretroviral therapy initiation to prevent development of LLV.

Differentiated Service Delivery Model in Improving HIV Treatment Outcomes Among Female Sex Workers in Gauteng Province of South Africa: A Protocol Paper

Differentiated Service Delivery Model in Improving HIV Treatment Outcomes Among Female Sex Workers in Gauteng Province of South Africa: A Protocol Paper

Adopting sustainable innovations for remote access to TB and HIV care in South Africa.

For the last decade, South Africa has made substantial progress to control the dual HIV and TB epidemics. However, disruptions in TB and HIV treatment during the COVID-19 pandemic threatened to reverse this. This study aimed to identify adaptations in HIV and TB service delivery models in response to COVID-19 and government restrictions. This information informed the development of an online survey, which was utilized as part of a consultation exercise to further capture adaptations made to HIV/TB service delivery within the South African context. The literature review involved screening 380 titles and abstracts, identifying 30 HIV and TB studies across 19 countries, and categorizing 90 individual interventions into ten thematic areas. Common themes included interventions addressing screening, testing, diagnosis, medication collection and delivery support, and virtual models. Digital health interventions and adaptations to medication collection/delivery were reported in 38% of studies. Analysis of survey responses from 33 stakeholders in South Africa revealed that 47% of interventions targeted HIV, 11% TB, and 23% HIV/TB integrated service delivery. Most interventions (81%) were integrated into the national HIV or TB program, with implementation occurring at various levels: 39% at facility level, 35% at sub-district or district level, and 18% at provincial level. Programmatic data was available for 86% of interventions, with 50% being funded. This study demonstrated that services can be delivered in locations other than in health facilities (e.g., community-based or home-based) and that integrated services can also free up additional resources. Although studies varied, COVID-19 accelerated the adoption of differentiated service delivery (DSD) models for TB care, including multi-month dispensing (MMD) for TB preventative therapy (TPT) and TB treatment, home-based or mobile outreach screening and testing, and community pickup points (PuP) for TB medications. These initiatives had previously lagged behind HIV-focused DSD models, and it is crucial to sustain these services beyond the pandemic. To achieve universal health coverage, it will also be important to capitalize on these experiences and learn from HIV-focused DSD models so programs can deliver integrated person-centered chronic care services for TB, HIV, and non-communicable diseases.

Differentiated Service Delivery Models for Maintaining HIV Treatment and Prevention Services During Crisis and Disease Outbreaks: Lessons from the COVID-19 Pandemic.

This review summarizes differentiated service delivery (DSD) models for HIV treatment and prevention that have been adapted for maintaining continuity of services during the COVID-19 pandemic and proposes strategies for sustaining their benefits now and during future disruptions. The COVID-19 pandemic resulted in an overburdened and disrupted health system, forcing countries to adopt and/or scale up DSD models for HIV services. While initially implemented as emergency measures, these models evolved and were refined over time to fit recipient needs ensuring continued HIV treatment and prevention services with minimal health system impact. Successful models employed task shifting, community-based delivery models, multimonth scripting and dispensing, and telehealth for remote consultation. DSD models enabled HIV services globally to be maintained during the COVID-19 pandemic. Though these models and adaptations were critical in addressing health gaps and disruptions caused by the pandemic, they were beneficial in improving efficiency and access to client-centered services and should be sustained.

Letter to the Editor: “Cost‐effectiveness and budget impact analysis of the implementation of differentiated service delivery models for HIV treatment in Mozambique: a modelling study”: Resource reductions are not equal to cost savings

Letter to the Editor: “Cost‐effectiveness and budget impact analysis of the implementation of differentiated service delivery models for HIV treatment in Mozambique: a modelling study”: Resource reductions are not equal to cost savings

Continuity of care during severe civil unrest with a model of community-based HIV care: a retrospective cohort study from Haiti

There are limited data on the effectiveness of differentiated service delivery (DSD) for HIV care during sociopolitical turmoil. We assessed outcomes with a DSD model of care that includes patient choice between community-based antiretroviral therapy (ART) centres, home-based ART dispensing, or facility-based care at GHESKIO clinic during a period of severe civil unrest in Port-au-Prince, Haiti. This retrospective analysis included data on patients with at least one HIV visit at GHESKIO between May 1, 2019, and December 31, 2021. Multivariable logistic regression models were used to assess predictors of attending ≥1 community visit during the study period, and failure to attend timely visits. HIV-1 RNA test results were reported among patients who had been ART for ≥3 months at last visit. Of the 18,625 patients included in the analysis, 9659 (51.9%) attended at least one community visit. The proportion of community visits ranged from 0.3% (2019) to 44.1% (2021). Predictors of ≥1 community visit includedmale sex (aOR: 1.13; 95% CI: 1.06, 1.20), secondary education (aOR: 1.07; 95% CI: 1.01, 1.14), income > $USD 1.00/day (aOR: 1.24; 95% CI: 1.14, 1.35), longer duration on ART (aOR: 1.08 per additional year; 95% CI: 1.07, 1.09), and residence in Carrefour/Gressier (p<0.0001 in comparisons with all other zones). Younger age and shorter time on ART were associated with late visits and loss to follow-up. Among 12,586 patients with an on-time final visit who had been on ART for ≥3 months, 11,131 (88.4%) received a viral load test and 9639 (86.6%) had HIV-1 RNA < 1000 copies/mL. The socio-political situation in Haiti has presented extraordinary challenges to the health care system, but retention and viral suppression rates remain high with a model of community-based HIV care. Additional interventions are needed to improve outcomes for younger patients, and those with shorter time on ART. No funding.

A Case Study on the Community ART Group Model of Care: Does It work for People Living with HIV and Healthcare Service Providers in Lesotho

The Community ART Group (CAG) model is a community-led model implemented to support people living with HIV to address barriers to HIV treatment continuity which remain a challenge in Lesotho. This study sought to explore the perspectives of people living with HIV and that of the healthcare service providers, regarding the CAG model in selected health facilities in Lesotho. An explorative descriptive qualitative study was conducted among purposively selected 20 people living with HIV and 8 healthcare service providers at 3 healthcare facilities. Qualitative data were collected through face-to-face in-depth interviews using semi-structured interview guides. All interviews were audio-recorded and transcribed verbatim. Thematic analysis was used following an inductive approach and sub-themes and themes were developed. The CAG model was relevant and acceptable to most of the respondents. They felt that it provided support to people living with HIV, promoted good adherence to treatment, improved treatment access, reduced transport costs, saved time, and reduced stigma. Good retention, favorable clinical outcomes and decongestion of health facilities were identified as key achievements linked to the CAG model. Age, proximity to the health facilities, readiness to disclose positive HIV status, availability of a variety of differentiated service delivery models, family support, and the level of trust emerged as factors affecting the acceptability of the model. Conflicts arising among members of the groups compromised service delivery quality and insufficient resources emerged as challenges. The results confirmed that the Community ART Group model can deliver intended peer-led support to People Living with HIV, resulting in the achievement of favorable clinical outcomes. It is therefore recommendable to consider investing in this community-led model for a sustained HIV response in the country.

Enhancing HIV treatment and support: a qualitative inquiry into client and healthcare provider perspectives on differential service delivery models in Uganda

BackgroundHIV/AIDS continues to be a significant contributor to illness and death, particularly in sub-Saharan Africa. In this study, we conducted a qualitative assessment to understand Client and Healthcare Provider Perspectives on Differential Service Delivery Models in Uganda. The purpose was to establish strengths and weaknesses within the services delivery models, inform policy and decision-making, and to facilitate context specific solutions.MethodsBetween February and April 2023, a qualitative cross-sectional study was utilised to gather insights from a targeted selection of individuals, including People Living with HIV (PLHIV), healthcare workers, HIV focal persons, community retail pharmacists, and various stakeholders. The data collection process included eleven in-depth interviews, nine key informant interviews, and eight focus group discussions carried out across eight districts in Central Uganda. The collected data was analyzed through inductive thematic analysis with the aid of Excel.ResultsThe various Differentiated Service Delivery Models (DSDMs), notably Community-Client-Led Drug Distribution (CCLAD), Community Drug Distribution Point (CDDP), Community Retail Pharmacy Drug Distribution Point (CRPDDP), and the facility-based Facility Based Individual Model (FBIM), were reported to have several positive impacts. These included improved treatment adherence, efficient management of antiretroviral (ARV) supplies, reduced exposure to infectious diseases, enhanced healthcare worker hospitality, minimized travel time for ART refills, stigma reduction, and decreased waiting times. Concern was raised about the lack of improvement in HIV status disclosure, opportunistic infection treatment, adherence to seasonal appointments, and sustainability due to the overreliance of the DSDMs on donor funding, suggesting potential discontinuation without funding. Doubts about health workers’ commitment surfaced. Notably, the CCLAD model displayed self-sustainability, with clients financially supporting group members to collect medicines.ConclusionCommunity-based DSDMs, such as CCLAD and CDDP, improve ART refill convenience, social support, and client experiences. These models reduce travel and waiting times, lowering infection risks. Addressing challenges and enhancing facility-based models is vital. In order to maintain funding after donor funding ends, sustainability measures like cross-subsidization can be used. If well implemented, the DSDMs have the potential to produce better or comparable ART outcomes compared to the FBIM model.

Assessing the Efficacy of Various Differentiated Service Delivery (DSD) Models in Chosen Healthcare Centers within Masaiti District.

Purpose: This study delves into the assessment of Differentiated Service Delivery (DSD) models within the healthcare framework of Masaiti District, focusing on their effectiveness, components, and implementation challenges. Methodology: Using a mixed method approach with explanatory embedded design, the study objectives encompass a multi-faceted exploration. These include an analysis of the specific components integrated into each DSD model adopted in Masaiti, an investigation into the interplay between facility level and individual stage participation in differentiated care, and an identification of the implementation difficulties faced in public health facilities. Findings: The study reveals a statistically significant connection (p &lt; 0.05) between facility stage participation and individual stage engagement in differentiated care, with a Cramer's V coefficient of 0.131 indicating a small effect size. This suggests a feasible relationship between the degree of individual participation in differentiated care and the facility's capacity to encourage and facilitate such participation. Unique contribution to theory, practice, and policy (recommendations):This research provides valuable insights for healthcare policymakers, practitioners, and stakeholders involved in the design, implementation, and improvement of DSD models. It highlights the distinctive features and methodologies of each DSD model in Masaiti District, the influence of healthcare facility hierarchies on DSD model effectiveness, and the challenges encountered during implementation. By addressing these aspects, the study offers recommendations to enhance the efficacy and sustainability of DSD initiatives within the Masaiti healthcare context.

Health System Responses to Address Treatment Gaps of Unsuppressed Adolescents on HIV Treatment in Public Primary Health Care Facilities in Windhoek, Namibia.

Adolescents living with HIV (ALHIV) face unique challenges that result in persistent gaps in achieving and maintaining suppressed viral load. Although effective evidence-based interventions to address treatment gaps in adolescents are readily available, health systems in resource-constrained, high HIV prevalence settings are challenged to implement them to achieve epidemic control. Here, we describe the health system responses to address the treatment gap of unsuppressed ALHIV on antiretroviral therapy in Windhoek, Namibia. We conducted a qualitative descriptive and exploratory study in Windhoek between June and October 2023. Nineteen purposively selected key informants, ranging from pediatric HIV program managers to healthcare providers, were interviewed. In-depth interviews were audio-recorded and transcribed verbatim. The transcripts were uploaded to ATLAS.ti and subjected to thematic analysis. The four main themes elucidated challenges related to adherence and retention as well as health system responses in the form of interventions and support programs. The predominant adherence and retention challenges faced by ALHIV were mental health issues, behavioral and medication-related challenges, and inadequate care and social support. The health system responses to the identified challenges included providing psychosocial support, peer support, optimization of treatment and care, and the utilization of effective service delivery models. Key health system support elements identified included adequately capacitated human resources, efficient medication supply chain systems, creating and maintaining an enabling environment for optimum care, and robust monitoring systems as essential to program success. The health system responses to address the remaining treatment gaps of unsuppressed ALHIV in Windhoek are quite varied and, although evidence-based, appear to be siloed. We recommend harmonized, multifaceted guidance, integrating psychosocial, treatment, care, and peer-led support, and strengthening client-centred differentiated service delivery models for unsuppressed adolescents.

Is the Differentiated Service Delivery Model Suited to the Needs of People Living with HIV in Rwanda?

The primary goal of antiretroviral treatment is to improve the health of individuals with HIV, and a secondary goal is to prevent further transmission. In 2016, Rwanda adopted the World Health Organization's "treat-all" approach in combination with the differentiated service delivery (DSD) model. The model's goal was to shorten the time from HIV diagnosis to treatment initiation, regardless of the CD4 T-cell count. This study sought to identify perceptions, enablers, and challenges associated with DSD model adoption among PLHIV.This study included selected health centers in Kigali city, Rwanda, between August and September 2022. The patients included were those exposed to the new HIV care model (DSD) model and those exposed to the previous model who transitioned to the current model. Interviews and focus group discussions were also held to obtain views and opinions on the DSD model. The data were collected via questionnaires and audio-recorded focus group discussions and were subsequently analyzed.The study identified several themes, including participants' initial emotions about a new HIV diagnosis, disclosure, experiences with transitioning to the DSD model, the effect of peer education, and barriers to and facilitators of the DSD model. Participants appreciated reduced clinic visits under the DSD model but faced transition and peer educator mobility challenges.The DSD model reduces waiting times, educates patients, and aligns with national goals. Identified barriers call for training and improved peer educator retention. Recommendations include enhancing the DSD model and future research to evaluate its long-term impact and cost-effectiveness.

Cost-Effectiveness and Budget Impact Analysis of the Implementation of Differentiated Service Delivery Models for HIV Treatment in Mozambique: a Modelling Study.

In 2018, the Mozambique Ministry of Health launched guidelines for implementing differentiated service delivery models (DSDMs) to optimize HIV service delivery, improve retention in care, and ultimately reduce HIV-associated mortality. The models were fast-track, 3-month antiretrovirals dispensing, community antiretroviral therapy groups, adherence clubs, family approach and three one-stop shop models: adolescent-friendly health services, maternal and child health, and tuberculosis. We conducted a cost-effectiveness analysis and budget impact analysis to compare these models to conventional services. We constructed a decision tree model based on the percentage of enrolment in each model and the probability of the outcome (12-month retention in treatment) for each year of the study period-three for the cost-effectiveness analysis (2019-2021) and three for the budget impact analysis (2022-2024). Costs for these analyses were primarily estimated per client-year from the health system perspective. A secondary cost-effectiveness analysis was conducted from the societal perspective. Budget impact analysis costs included antiretrovirals, laboratory tests and service provision interactions. Cost-effectiveness analysis additionally included start-up, training and clients' opportunity costs. Effectiveness was estimated using an uncontrolled interrupted time series analysis comparing the outcome before and after the implementation of the differentiated models. A one-way sensitivity analysis was conducted to identify drivers of uncertainty. After implementation of the DSDMs, there was a mean increase of 14.9 percentage points (95% CI: 12.2, 17.8) in 12-month retention, from 47.6% (95% CI, 44.9-50.2) to 62.5% (95% CI, 60.9-64.1). The mean cost difference comparing DSDMs and conventional care was US$ -6 million (173,391,277 vs. 179,461,668) and -32.5 million (394,705,618 vs. 433,232,289) from the health system and the societal perspective, respectively. Therefore, DSDMs dominated conventional care. Results were most sensitive to conventional care interaction costs in the one-way sensitivity analysis. For a population of 1.5 million, the base-case 3-year financial costs associated with the DSDMs was US$550 million, compared with US$564 million for conventional care. DSDMs were less expensive and more effective in retaining clients 12 months after antiretroviral therapy initiation and were estimated to save approximately US$14 million for the health system from 2022 to 2024.

Differentiated service delivery framework for people with multidrug-resistant tuberculosis and HIV co-infection.

For people living with HIV/AIDS, care is commonly delivered through Differentiated Service Delivery (DSD). Although people with multidrug-resistant tuberculosis (MDR-TB) and HIV/AIDS experience severe treatment associated challenges, there is no DSD model to support their treatment. In this study, we defined patterns of medication adherence and characterized longitudinal barriers to inform development of an MDR-TB/HIV DSD framework. Adults with MDR-TB and HIV initiating bedaquiline (BDQ) and receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa, were enrolled and followed through the end of MDR-TB treatment. Electronic dose monitoring devices (EDM) measured BDQ and ART adherence. Longitudinal focus groups were conducted and transcripts analyzed thematically to describe discrete treatment stage-specific and cross-cutting treatment challenges. 283 participants were enrolled and followed through treatment completion (median 17.8 months [IQR 16.5-20.2]). Thirteen focus groups were conducted. Most participants (82.7%, 234/283) maintained high adherence (mean BDQ adherence 95.3%; mean ART adherence 85.5%), but an adherence-challenged subpopulation with <85% cumulative adherence (17.3%, 49/283) had significant declines in mean weekly BDQ adherence from 94.9% to 39.9% (p<0.0001) and mean weekly ART adherence from 83.9% to 26.6% (p<0.0001) over 6 months. Psychosocial, behavioral, and structural obstacles identified in qualitative data were associated with adherence deficits in discrete treatment stages, and identified potential stage specific interventions. A DSD framework for MDR-TB/HIV should intensify support for adherence-challenged subpopulations, provide multi-modal support for adherence across the treatment course and account for psychosocial, behavioral, and structural challenges linked to discrete treatment stages.

Satisfaction with service delivery among HIV treatment clients enrolled in differentiated and conventional models of care in South Africa: a baseline survey.

Differentiated service delivery (DSD) models aim to increase the responsiveness of HIV treatment programmes to the individual needs of antiretroviral therapy (ART) clients to improve treatment outcomes and quality of life. Little is known about how DSD client experiences differ from conventional care. From May to November 2021, we interviewed adult (≥18) ART clients at 21 primary clinics in four districts of South Africa. Participants were enrolled consecutively at routine visits and stratified into four groups: conventional care-not eligible for DSD (conventional-not-eligible); conventional care eligible for but not enrolled in DSD (conventional-not-enrolled); facility pickup point DSD model; and external pickup point DSD model. Satisfaction was assessed using questions with 5-point Likert-scale responses. Mean scores were categorized as not satisfied (score ≤3) or satisfied (>3). We used logistic regression to assess differences and report crude and adjusted odds ratios (aORs). Qualitative themes were identified through content analysis. Eight hundred and sixty-seven participants (70% female, median age 39) were surveyed: 24% facility pick-up points; 27% external pick-up points; 25% conventional-not-eligible; and 24% conventional-not-enrolled. Seventy-four percent of all study participants expressed satisfaction with their HIV care. Those enrolled in DSD models were more likely to be satisfied, with an aOR of 6.24 (95% CI [3.18-12.24]) for external pick-up point versus conventional-not-eligible and an aOR of 3.30 (1.95-5.58) for facility pick-up point versus conventional-not-eligible. Conventional-not-enrolled clients were slightly but not significantly more satisfied than conventional-not-eligible clients (1.29, 0.85-1.96). Those seeking outside healthcare (crude OR 0.57, 0.41-0.81) or reporting more annual clinic visits (0.52, 0.29-0.93) were less likely to be satisfied. Conventional care participants reporting satisfaction with their current model of care perceived providers as helpful, respectful, and friendly and were satisfied with care despite long queues. DSD model participants emphasized ease and convenience, particularly not having to queue. Most adult ART clients in South Africa were satisfied with their care, but those enrolled in DSD models expressed slightly greater satisfaction than those remaining in conventional care. Efforts should focus on enrolling more eligible patients into DSD models, expanding eligibility criteria to cover a wider client base, and further improving the models' desirable characteristics.

HIV Viral Load Patterns and Risk Factors Among Women in Prevention of Mother-To-Child Transmission Programs to Inform Differentiated Service Delivery.

Differentiated service delivery (DSD) approaches decrease frequency of clinic visits for individuals who are stable on antiretroviral therapy. It is unclear how to optimize DSD models for postpartum women living with HIV (PWLH). We evaluated longitudinal HIV viral load (VL) and cofactors, and modelled DSD eligibility with virologic failure (VF) among PWLH in prevention of mother-to-child transmission programs. This analysis used programmatic data from participants in the Mobile WAChX trial (NCT02400671). Women were assessed for DSD eligibility using the World Health Organization criteria among general people living with HIV (receiving antiretroviral therapy for ≥6 months and having at least 1 suppressed VL [<1000 copies/mL] within the past 6 months). Longitudinal VL patterns were summarized using group-based trajectory modelling. VF was defined as having a subsequent VL ≥1000 copies/mL after being assessed as DSD-eligible. Predictors of VF were determined using log-binomial models among DSD-eligible PWLH. Among 761 women with 3359 VL results (median 5 VL per woman), a 3-trajectory model optimally summarized longitudinal VL, with most (80.8%) women having sustained low probability of unsuppressed VL. Among women who met DSD criteria at 6 months postpartum, most (83.8%) maintained viral suppression until 24 months. Residence in Western Kenya, depression, reported interpersonal abuse, unintended pregnancy, nevirapine-based antiretroviral therapy, low-level viremia (VL 200-1000 copies/mL), and drug resistance were associated with VF among DSD-eligible PWLH. Most postpartum women maintained viral suppression from early postpartum to 24 months and may be suitable for DSD referral. Women with depression, drug resistance, and detectable VL need enhanced services.

The Acceptability, Feasibility, and Preliminary Effectiveness of a Courier HIV-Treatment Delivery and SMS Support Intervention for Young People Living With HIV in South Africa.

Young people living with HIV (YPLWH) experience poorer rates of virological suppression compared with adults. Differentiated service delivery models for YPLWH are urgently needed to address this disparity. Participants were recruited from an HIV treatment clinic near Cape Town, South Africa. We conducted a longitudinal pilot study to examine the acceptability, feasibility, and preliminary effectiveness of a courier ART delivery and SMS support intervention to retain YPLWH (13-24 years) in care during COVID-19. YPLWH had the option to enroll in the courier service and were randomized 1:1 to receive adherence support via a weekly SMS. Modified Poisson regression was used to estimate the preliminary effectiveness of the courier intervention on viral suppression (HIV-1 RNA <200 copies/mL) at months 3 and 6. Among 215 participants, 82% elected to enroll in the courier ART service at baseline, 41% reported receiving a delivery in the past 3 months at month 3, and 49% reported receiving a delivery in the past 3 months at month 6. Among those who received a delivery, most (91%-100%) rated the intervention as acceptable. Participants who reported receiving a delivery in the past 3 months at month 3 were 1.26 (95% CI: 1.05, 1.54) times as likely to have a suppressed viral load at month 3 and 1.21 (0.99, 1.48) times as likely at month 6, controlling for potential confounders. Findings reveal high uptake and acceptability of a courier ART delivery intervention among YPLWH and promising evidence for its effectiveness in increasing the probability of viral suppression. A fully powered trial is warranted.

Virological and care outcomes of community ART distribution: Experience with the PODI+ model in Kinshasa, Democratic Republic of the Congo.

Differentiated service delivery models for HIV treatment can minimize unnecessary burdens on health systems and promote efficient delivery of antiretroviral therapy (ART). Under the PODI+ (poste de distribution communautaire) model, ART multi-month dispensation (MMD) was provided by lay workers (peers) in communities. We compared outcomes among clinically stable adults living with HIV receiving MMD via PODI+ or health facility (HF). Clients receiving MMD at nine HFs and two PODI+ sites in Kinshasa were followed prospectively for one year (2018-2020). Medication possession ratio (MPR) was measured as proportion of total days with medication during the study through record abstraction at 3-month intervals. Viral load was assessed at enrollment and 12 months. We compared MPR and viral load suppression by arm and examined associations and potential confounders using unadjusted and adjusted odds ratios (AOR). Likert-style client satisfaction was collected during 12-month interviews and described by arm. Odds of maintaining viral load suppression at 12 months for PODI+ participants were two times that for HF participants. In adjusted models, PODI+ participants had 1.89 times the odds of being suppressed at 12 months compared to HF participants (95% CI: 1.10, 3.27). No significant differences in MPR were found between groups (OR: 0.86, 0.38-1.99). Older participants had significantly higher odds of MPR (AOR: 1.02, 95% CI: 1.01, 1.03) and viral suppression (AOR: 1.03, 95% CI: 1.00, 1.07). Satisfaction with services was ≥87% overall, but PODI+ participants rated time spent at site, provider attributes and other care aspects more favorably. Participants receiving MMD via peer-run community distribution points had similar MPR, but better virological outcomes and greater satisfaction with care than clinically similar participants receiving MMD through facilities. PODI+ could be a useful model for expansion to serve larger clinic populations from overburdened health facilities, particularly as policy shifts towards more inclusive MMD eligibility requirements.

Isoniazid preventive therapy completion between July-September 2019: A comparison across HIV differentiated service delivery models in Uganda.

Tuberculosis (TB) remains the leading cause of death among people living with HIV (PLHIV). To prevent TB among PLHIV, the Ugandan national guidelines recommend Isoniazid Preventive Therapy (IPT) across differentiated service delivery (DSD) models, an effective way of delivering ART. DSD models include Community Drug Distribution Point (CDDP), Community Client-led ART Delivery (CCLAD), Facility-Based Individual Management (FBIM), Facility-Based Group (FBG), and Fast Track Drug Refill (FTDR). Little is known about the impact of delivering IPT through DSD. We reviewed medical records of PLHIV who initiated IPT between June-September 2019 at TASO Soroti (TS), Katakwi Hospital (KH) and Soroti Regional Referral Hospital (SRRH). We defined IPT completion as completing a course of isoniazid within 6-9 months. We utilized a modified Poisson regression to compare IPT completion across DSD models and determine factors associated with IPT completion in each DSD model. Data from 2968 PLHIV were reviewed (SRRH: 50.2%, TS: 25.8%, KH: 24.0%); females: 60.7%; first-line ART: 91.7%; and Integrase Strand Transfer Inhibitor (INSTI)-based regimen: 61.9%. At IPT initiation, the median age and duration on ART were 41.5 (interquartile range [IQR]; 32.3-50.2) and 6.0 (IQR: 3.7-8.6) years, respectively. IPT completion overall was 92.8% (95%CI: 91.8-93.7%); highest in CDDP (98.1%, 95%CI: 95.0-99.3%) and lowest in FBG (85.8%, 95%CI: 79.0-90.7%). Compared to FBIM, IPT completion was significantly higher in CDDP (adjusted rate ratio [aRR] = 1.15, 95%CI: 1.09-1.22) and CCLAD (aRR = 1.09, 95% CI 1.02-1.16). In facility-based models, IPT completion differed between sites (p<0.001). IPT completion increased with age for FBIM and CCLAD and was lower among female participants in the CCLAD (aRR = 0.82, 95%CI 0.67-0.97). IPT completion was high overall but highest in community-based models. Our findings provide evidence that supports integration of IPT within DSD models for ART delivery in Uganda and similar settings.

Uptake and associated factors of six multi-month scripting/appointment spacing differentiated service delivery model of care among stable clients on antiretroviral therapy in Southern Ethiopia.

Differentiated service delivery models have been developed to accommodate the rising number of stable antiretroviral therapy clients and to maintain improvements in health outcomes and care retention. Ethiopia adopted the appointment spacing model and has had notable successes in implementing it. However, with the implementation of the six multi-month scripting/appointment spacing model in Ethiopia, little is known about the uptake and its associated factors. Therefore, this study aimed to assess the uptake and associated factors of the six multi-month scripting/appointment spacing differentiated service delivery model of care among stable clients on antiretroviral therapy in Southern Ethiopia. A hospital-based cross-sectional study was conducted among 419 stable clients on antiretroviral therapy in southern Ethiopia from June 22 to September 29, 2023. A systematic sampling technique was used to select the study participants. Using a structured questionnaire, socio-demographic, health service delivery, behavioral, and clinical-related data were collected. The collected data were entered into Epi Data version 3.1 and analyzed using Stata version 14. Variables with a P-value <0.05 in the multivariable logistic analysis were considered statistically significant. Multicollinearity and model fitness were checked using the variance inflation factor and the Hosmer and Lemeshow goodness of fit tests, respectively. The uptake of the six multi-month scripting/appointment spacing differentiated service delivery model of care was 63.25% (95% confidence interval (CI): 58.61%, 67.88%). Missed appointment (Adjusted Odds Ratio (AOR): 1.91 (95% CI: 1.13, 3.25)), distance to antiretroviral therapy facility (AOR: 2.90 (95% CI: 1.67, 5.04)), duration on antiretroviral therapy (AOR: 2.21 (95% CI: 1.34, 3.64)), and intermediate social support (AOR: 2.02 (95% CI: 1.29, 3.17)) and strong social support (AOR: 2.71 (95% CI: 1.23, 5.97)) were factors significantly associated with the uptake. The uptake of six multi-month scripting/appointment spacing differentiated service delivery models of care was six out of ten clients on antiretroviral therapy. To further improve the uptake, a precise intervention on the identified associated factor is required.