Differentiated Service Delivery Models Research Articles

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.

Transitional community adherence support for people leaving incarceration in South Africa: a pragmatic, open-label, randomised controlled trial

People released from correctional facilities face multifactorial barriers to continuing HIV treatment. We hypothesised that barriers faced in the first 6 months of community re-entry would be decreased by a multilevel group-based and peer-led intervention, the Transitional Community Adherence Club (TCAC). We did a pragmatic, open-label, individually randomised controlled trial in five correctional facilities in Gauteng, South Africa. Participants aged 18 years and older and receiving antiretroviral therapy (ART) in correctional facilities were enrolled before release and randomly assigned (1:2) to either passive referral (usual care) or TCACs. TCACs followed a 12-session curriculum over 6 months and were facilitated by trained peer and social workers. Participants were followed up by telephone and in person to assess the primary outcome: post-release enrolment in HIV treatment services at 6 months from the date of release. We did an intention-to-treat analysis to determine the effectiveness of TCACs compared with usual care. The trial was registered with the South African National Clinical Trials Register (DOH-27-0419-605) and ClinicalTrials.gov (NCT03340428). This study is completed and is listed as such on ClinicalTrials.gov. From March 1, to Dec 13, 2019, we screened 222 individuals and enrolled 176 participants who were randomly assigned 1:2 to the usual care group (n=59) or TCACs (n=117). 175 participants were included in the final analysis. In the usual care group, 21 (36%) of 59 participants had enrolled in HIV treatment services at 6 months, compared with 71 (61%) of 116 in the TCAC group (risk ratio 1·7, 95% CI 1·2-2·5; p=0·0010). No adverse events were reported. We found strong evidence that a differentiated service delivery model with curriculum and peer support designed specifically to address the needs of people with HIV returning from incarceration improved the primary outcome of enrolment in HIV treatment services. Our approach is a reasonable model to build further HIV treatment continuity interventions for individuals in the criminal justice system in South Africa and elsewhere. National Institute of Mental Health.

Willingness to pay for antiretroviral therapy, viral load, and premium services; A contingent valuation survey of people living with HIV in southern Nigeria.

With stagnating funding for HIV and AIDS control programs in Nigeria, alternative funding models for antiretroviral therapy (ART) including out of pocket payment are being considered to sustain momentum epidemic control targets. We assessed willingness to pay for ART related services, and factors associated with willingness to pay. Between July and August 2019, we conducted a survey among people living with HIV (PLHIV) on ART in 3 states in southern Nigeria. Randomly sampled respondents on ART for at least 6 months, aged ≥ 18 years, able to communicate in English or pidgin English, and consenting to the survey were enrolled. Respondents were asked if they were willing to pay for clinical consultation, antiretroviral drugs (ARVs), viral load testing services and premium ART services (including fast track services). Respondents indicating willingness to pay for any of these services were asked the maximum amount they were willing to pay using contingent valuation methodology. We assessed the weighted proportions of PLHIV on ART willing to pay for ART and used survey-featured logistic regression measures to assess sociodemographic and ART related factors associated with willingness to pay for ART services. Overall, 1,598 PLHIV with a mean age of 39.03 years (standard deviation [SD]: 11.23 years), were included in this analysis. Of these, 65.8% (1,079), 73.9% (1,192), 61.0% (995) and 33.6% (472) were willing to pay for ART consultation, ARVs, viral load testing services and premium ART services respectively. The median maximum amount PLHIV were willing to pay for clinical consultation and for ARVs was NGN1,000 (USD equivalent of $2.78; interquartile range [IQR]: 500-2,000) respectively, and NGN2,500 (USD equivalent of $6.94; IQR: NGN1,000-5,000) and NGN2,000 (USD equivalent of $5.56; IQR: NGN1,000-3,000) for viral load testing and premium ART services respectively. Receiving ART in Lagos state, being employed and having a monthly income of NGN100,000 or more was associated with willingness to pay for the various ART services. We found generally high-level of willingness to pay for ART consultation, ARVs and viral load testing services but low willingness to pay for premium ART services among PLHIV on ART. The maximum amount PLHIV were willing to pay for various ART services fell short of benchmarks for alternative funding but can potentially supplement ART by funding differentiated service delivery models that require nominal amounts to facilitate person-centered differentiated service delivery models.

Identifying longitudinal patterns of HIV treatment (dis)engagement and re-engagement from oral histories of virologically unsuppressed persons in Uganda: A thematic trajectory analysis

BackgroundThere is limited study of persons deemed “harder to reach” by HIV treatment services, including those discontinuing or never initiating antiretroviral therapy (ART). We conducted narrative research in southern Uganda with virologically unsuppressed persons identified through population-based sampling to discern longitudinal patterns in HIV service engagement and identify factors shaping treatment persistence. MethodsIn mid-2022, we sampled adult participants with high-level HIV viremia (≥1000 RNA copies/mL) from the prospective, population-based Rakai Community Cohort Study. Using life history calendars, we conducted initial and follow-up in-depth interviews to elicit oral histories of participants’ journeys in HIV care, from diagnosis to the present. We then used thematic trajectory analysis to identify discrete archetypes of HIV treatment engagement by “re-storying” participant narratives and visualizing HIV treatment timelines derived from interviews and abstracted clinical data. ResultsThirty-eight participants (median age: 34 years, 68% men) completed 75 interviews. We identified six HIV care engagement archetypes from narrative timelines: (1) delayed ART initiation, (2) early treatment discontinuation, (3) treatment cycling, (4) prolonged treatment interruption, (5) transfer-related care disruption, and (6) episodic viremia. Patterns of service (dis)engagement were highly gendered, occurred in the presence and absence of optimal ART adherence, and were shaped by various factors emerging at different time points, including: denial of HIV serostatus and disclosure concerns; worsening HIV-related symptoms; psychological distress and depression; social support; intimate partner violence; ART side effects; accessibility constraints during periods of mobility; incarceration; and inflexible ART dispensing regulations. ConclusionsIdentified trajectories uncovered heterogeneities in both the timing and drivers of ART (re-)initiation and (dis)continuity, demonstrating the distinct characteristics and needs of people with different patterns of HIV treatment engagement throughout the life course. Enhanced mental health service provision, expanded eligibility for differentiated service delivery models, and streamlined facility switching processes may facilitate timely (re-)engagement in HIV services.

Preferences of Pregnant and Postpartum Women for Differentiated Service Delivery in Kenya.

Differentiated service delivery models are implemented by HIV care programs globally, but models for pregnant and postpartum women living with HIV (PPWH) are lacking. We conducted a discrete choice experiment to determine women's preferences for differentiated service delivery. Five public health facilities in western Kenya. PPWH were enrolled from April to December 2022 and asked to choose between pairs of hypothetical clinics that differed across 5 attributes: clinic visit frequency during pregnancy (monthly vs. every 2 months), postpartum visit frequency (monthly vs. only with routine infant immunizations), seeing a mentor mother (each visit vs. as needed), seeing a clinician (each visit vs. as needed), and basic consultation cost (0, 50, or 100 Kenya Shillings [KSh]). We used multinomial logit modeling to determine the relative effects (β) of each attribute on clinic choice. Among 250 PPWH (median age 31 years, 42% pregnant, 58% postpartum, 20% with a gap in care), preferences were for pregnancy visits every 2 months (β = 0.15), postpartum visits with infant immunizations (β = 0.36), seeing a mentor mother and clinician each visit (β = 0.05 and 0.08, respectively), and 0 KSh cost (β = 0.39). Preferences were similar when stratified by age, pregnancy, and retention status. At the same cost, predicted market choice for a clinic model with fewer pregnant/postpartum visits was 75% versus 25% for the standard of care (ie, monthly visits during pregnancy/postpartum). PPWH prefer fewer clinic visits than currently provided within the standard of care in Kenya, supporting the need for implementation of differentiated service delivery for this population.

A Community-Based, Mobile Electronic Medical Record System App for High-Quality, Integrated Antiretroviral Therapy in Lilongwe, Malawi: Design Process and Pilot Implementation.

Differentiated service delivery (DSD) increases antiretroviral therapy (ART) access in sub-Saharan Africa by moving clients out of congested ART clinics to communities for care. However, DSD settings challenge provider adherence to complex, chronic care treatment guidelines and have burdensome systems for client monitoring and evaluation (M&E), reducing data for decision-making. Electronic medical record systems (EMRS) improve client outcomes and reduce M&E workload. Traditional EMRS cannot operate in most DSD settings with unreliable power and poor connectivity. This study aims to detail the human-centered design (HCD) process of developing a mobile EMRS for community-based DSD services in Lilongwe, Malawi. Lighthouse Trust (LT) operates 2 Ministry of Health (MoH) clinics in Lilongwe, Malawi, with a combined total of >35,000 ART clients. LT's real-time, point-of-care EMRS collects complex client M&E data and provides decision-making support, ensuring adherence to integrated HIV and tuberculosis guidelines that optimize client and program outcomes. LT's EMRS scaled to all large MoH ART clinics. LT also implements a nurse-led community-based ART program (NCAP), a DSD model to provide ART and rapid assessment for 2400 stable LT clients in the community. LT, alongside collaborators, from the University of Washington's International Training and Education Center for Health and technology partner, Medic, used the open-source Community Health Toolkit (CHT) and HCD to develop an open-source, offline-first, mobile EMRS-like app, "community-based ART retention and suppression" (CARES). CARES aims to bring EMRS-like provider benefits to NCAP's DSD clients. CARES design took approximately 12 months and used an iterative process of highly participatory feedback sessions with provider, data manager, and M&E team inputs to ensure CARES optimization for the NCAP and LT settings. The CARES mobile EMRS prototype supports NCAP providers with embedded prompts and alerts to ensure adherence to integrated MoH ART guidelines, aiming to improve the quality of client care. CARES facilitates improved data quality and flow for NCAP M&E, aiming to reduce data gaps between community and clinic settings. The CARES pilot demonstrates the potential of a mobile, point-of-care EMRS-like app that could benefit NCAP clients, providers, and program teams with integrated client care and complete M&E data for decision-making. CARES challenges include app speed, search features to align longitudinal records, and CARES to EMRS integration that supports timely care alerts. Leveraging the CHT and HCD processes facilitated the design of a locally specified and optimized mobile app with the promise to bring EMRS-like benefits to DSD settings. Moving from the CARES prototype to routine NCAP implementation should result in improved client care and strengthened M&E while reducing workload. Our transparent and descriptive process shares the progress and pitfalls of the CARES design and development, helping others in this digital innovation area to learn from our experiences at this stage.

Predictors of Detectable Viremia, Outcomes, and Implications for Management of People Living With HIV Who Are Receiving Antiretroviral Therapy in Southern Nigeria

Abstract Background This study examined the prevalence and factors associated with detectable viremia, as well as clinical outcomes among people with HIV (PWH) receiving antiretroviral therapy (ART) who initially achieved viral suppression in 2 southern states in Nigeria. Methods The retrospective cohort study used data from the electronic medical records of 96 comprehensive ART centers. PWH were followed up who achieved viral suppression (viral load [VL] ≤50 copies/mL) upon starting ART based on the first VL test. We examined the presence of detectable viremia in follow-up VL results, graded by the absolute VL count from the second and third consecutive VL tests as follows: transient viremia (second follow-up VL, 51–999 copies/mL; third, ≤50 copies/mL), persistent viremia (second follow-up VL, 51–999 copies/mL or ≥1000 copies/mL; third, &amp;gt;50 copies/mL), and virologic failure (second and third follow-up VL, &amp;gt;1000 copies/mL). We analyzed demographic and clinical factors associated with detectable viremia using logistic regression analysis on Stata 14. Results Overall, 15 050 PWH had achieved viral suppression following ART initiation (median age, 34 years; 71.3% female). On follow-up, 3101 (20.6%) had a viremic event: 11.6%, transient viremia; 8.8%, persistent viremia; 0.2%, virologic failure. Shorter duration of ART (P &amp;lt; .001), being 0 to 14 years of age (P &amp;lt; .001), and not being enrolled in a differentiated service delivery model (P &amp;lt; .001) were significantly associated with detectable viremia. Conclusions Our study shows that people who initially attain vial suppression upon starting ART remain at risk of detectable viremia.

Is adherence to antiretroviral therapy by recipients of HIV care and treatment receiving care in Akwa Ibom state, Nigeria determined by their behaviors? A cross-sectional study

Background: There has been limited use of stage of change model in scaling up self-care for optimal adherence to ART. The study aimed to assess the pattern of behavior and its associated factors among recipients of care (RoC) receiving treatment in Akwa Ibom state, Nigeria. Methods: A descriptive cross-sectional study was conducted among 423 RoC between August and October 2022. The pattern of behavior of RoC was determined using descriptive statistics, and factors associated with behavior were assessed using chi-square analysis and subsequently binary logistic regression at an alpha level of &lt;0.05 at a 95% confidence interval using SPSS version 25. Results: Out of 423 recipients on care interviewed, 85% were in maintenance phase, and 13% in action phase. The correlates of behaviors of RoC were HIV diagnosis and on ART for over a year (p&lt;0.001), residing in rural settings (p&lt;0.001), and those in clinically stable DSD models (p&lt;0.001). Over 87% of those in maintenance phase were adherent to ART, however, this was not statistically significant (p=0.21). Conclusions: Almost all the RoC were in good behavior and majority of them were adherent to ART. The factors associated with behavior of recipients of care were those diagnosed and on ART for over a year, residing in rural settings, and those in clinically stable differentiated service delivery (DSD) models. Interventions that utilize stage of change model to scale up the self-care of RoC particularly among those in the urban settings is highly imperative.

Assessment of knowledge of differentiated service delivery among HIV-positive patients receiving care in a Southeastern Nigerian State

Background: Since the adoption of the differentiated service delivery (DSD) as a programmatic strategy in the delivery of antiretroviral therapy (ART) in Imo state, no research has assessed the level of knowledge of DSD among HIV-positive patients receiving ART in the state, a research gap which this study aimed to fill.&#x0D; Methods: This was a cross sectional study carried out among the adult patients receiving ART in three DSD models and the usual care group at one tertiary and three secondary hospitals using a structured questionnaire validated by the researcher. Descriptive and inferential analyses were performed using the statistical product and service solutions (SPSS) version 24. All the analysis was performed at p≤0.05.&#x0D; Results: Of the 542 questionnaires retrieved, the female gender was predominant in all the groups. Up to 57.3% and 55.5% of the patients had good knowledge and perception towards differentiated care respectively. A significant difference was found in the mean perception among the groups (F (3.538)=9.309, p&lt;0.05). While education and participation in HIV activities were found to be significant predators of knowledge of DSD, (F (10.466)=3.082, R2 of 0.062, p&lt;0.05), only education was found to be determinant of perception.&#x0D; Conclusions: This study has shown that the patients had fair knowledge of the DSD in all the models examined, as well as the usual group; and this did not differ significantly across the groups. However, there is need to improve on patients' enlightenment of the initiative, especially for those in the usual care group.

Pathways to care with HIV-associated cryptococcal meningitis in Botswana and Uganda: Findings from a qualitative methods study

HIV-associated cryptococcal meningitis remains a key driver of AIDS-related mortality. Mortality is twice as high in those who present later to care and with severe symptoms such as confusion. We embedded a qualitative methods study within a randomised controlled trial in Gaborone, Botswana and Kampala, Uganda with the aim of understanding pathways to care. We conducted in-depth interviews with trial participants and surrogate decision makers and analysed data thematically. Between January 2020 and June 2021 we interviewed 58 individuals. Pathways to care were prolonged because headaches were disregarded by participants and healthcare workers as a common occurrence with a broad differential diagnosis of predominantly benign aetiologies. There was also a lack of awareness of cryptococcal meningitis, and it was often after HIV was diagnosed or disclosed that the pathway accelerated, resulting in hospital admission. We outline key recommendations to reduce mortality and argue for the integration of social and behavioural interventions within differentiated service delivery models for advanced HIV disease.

Impact of differentiated service delivery models on 12-month retention in HIV treatment in Mozambique: an interrupted time-series analysis

HIV treatment has been available in Mozambique since 2004, but coverage of, and retention in, antiretroviral therapy (ART) remain suboptimal. Therefore, to increase health system efficiency and reduce HIV-associated mortality, in November, 2018, the Ministry of Health launched national guidelines on implementing eight differentiated service delivery models (DSDMs) for HIV treatment. We assessed the effect of this implementation on retention in ART 12 months after initiation, and explored the associated effects of COVID-19. In this uncontrolled interrupted time-series analysis, data were extracted from the Mozambique ART database, which contains data on individuals in ART care from 1455 health facilities providing ART in Mozambique. We included individual-level data from facilities that were providing ART at the beginning of the study period (Jan 1, 2016) and at the start of DSDM implementation (Dec 1, 2018). We compared the proportion of individuals retained in ART 12 months after initiation between the periods before (Jan 1, 2017, to Nov 30, 2018) and after (Dec 1, 2019, to June 30, 2021) implementation of the DSDMs, overall and stratified by sex and age. We applied a generalised estimating equation model with a working independence correlation and cluster-robust standard errors to account for clustering at the facility level. In a secondary analysis, we assessed the effect of COVID-19 response measures during the post-intervention period on ART retention. The study included 613 facilities and 1 131 118 individuals who started ART during the inclusion period up to June 30, 2020, of whom 79 178 (7·0%) were children (age ≤14 years), 226 224 (20·0%) were adolescents and young adults (age 15-24 years), and 825 716 (73·0%) were adults (age ≥25 years). 731 623 (64·7%) were female and 399 495 (35·3%) were male. Introduction of the DSDMs was associated with an estimated increase of 24·5 percentage points (95% CI 21·1 to 28·0) in 12-month ART retention by the end of the study period, compared with the counterfactual scenario without DSDM implementation. By age, the smallest effect was estimated in children (6·1 percentage points, 1·3 to 10·9) and the largest effect in adolescents and young adults (28·8 percentage points, 24·2 to 33·4); by sex, a larger effect was estimated in males (29·7 percentage points, 25·6 to 33·7). Our analysis showed that COVID-19 had an overall negative effect on 12-month retention in ART compared with a counterfactual scenario based on the post-intervention period without COVID-19 (-10·0 percentage points, -18·2 to -1·8). The implementation of eight DSDMs for HIV treatment had a positive impact on 12-month retention in ART. COVID-19 negatively influenced this outcome. None. For the Portuguese translation of the abstract see Supplementary Materials section.

Provider-led community antiretroviral therapy distribution in Malawi: Retrospective cohort study of retention, viral load suppression and costs.

Outcomes of community antiretroviral therapy (ART) distribution (CAD), in which provider-led ART teams deliver integrated HIV services at health posts in communities, have been mixed in sub-Saharan African countries. CAD outcomes and costs relative to facility-based care have not been reported from Malawi. We performed a retrospective cohort study in two Malawian districts (Lilongwe and Chikwawa districts), comparing CAD with facility-based ART care. We selected an equal number of clients in CAD and facility-based care who were aged >13 years, had an undetectable viral load (VL) result in the last year and were stable on first-line ART for ≥1 year. We compared retention in care (alive and no period of ≥60 days without ART) using Kaplan-Meier survival analysis and Cox regression and maintenance of VL suppression (<1,000 copies/mL) during follow-up using logistic regression. We also compared costs (in US$) from the health system and client perspectives for the two models of care. Data were collected in October and November 2020. 700 ART clients (350 CAD, 350 facility-based) were included. The median age was 43 years (IQR 36-51), median duration on ART was 7 years (IQR 4-9), and 75% were female. Retention in care did not differ significantly between clients in CAD (89.4% retained) and facility-based care (89.3%), p = 0.95. No significant difference in maintenance of VL suppression were observed between CAD and facility-based care (aOR: 1.24, 95% CI: 0.47-3.20, p = 0.70). CAD resulted in slightly higher health system costs than facility-based care: $118/year vs. $108/year per person accessing care; and $133/year vs. $122/year per person retained in care. CAD decreased individual client costs compared to facility-based care: $3.20/year vs. $11.40/year per person accessing care; and $3.60/year vs. $12.90/year per person retained in care. Clients in provider-led CAD care in Malawi had very good retention in care and VL suppression outcomes, similar to clients receiving facility-based care. While health system costs were somewhat higher with CAD, costs for clients were reduced substantially. More research is needed to understand the impact of other differentiated service delivery models on costs for the health system and clients.

The HIV/AIDS responses pre and during the COVID-19 pandemic in sub-Saharan Africa: A basis for sustainable health system strengthening post–COVID-19

In May 2023, the World Health Organization announced that COVID-19 was no longer a global emergency. The impact of COVID-19 on the provision of HIV/AIDS services was not that severe due to the reprogramming of key resources. For health systems in sub-Saharan Africa to become resilient to future pandemics, lessons should be learned from the successful HIV/AIDS response in the region, and how the HIV/AIDS services were successfully adapted to the COVID-19 pandemic. In this article, we reviewed the 6 World Health Organization health system building blocks on how the best practices from the provision of HIV/AIDS services and the services’ response to the COVID-19 pandemic can be used as a basis for restoring and strengthening health systems to offer universal access to quality essential health services. The success of the leadership and governance for universal access to anti-retroviral therapy can be a blueprint for the realization of universal health coverage. Significant efficiencies that resulted in the reduction in anti-retroviral therapy costs can be leveraged to ensure cheaper essential drugs while differentiated service delivery models can be used to improve health service accessibility. New technologies that have proven to be successful in HIV/AIDS care can also be used in the care of other diseases, including disease outbreaks. The strong health information systems developed for HIV programs can be used as a foundation for developing health information systems for the whole health sector while the healthcare professionals trained for the provision of HIV/AIDS services can be trained to provide services for a variety of other conditions.