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Similarities and differences between the three antiretroviral treatment delivery models (Mukumbang, 2021).
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Differentiated service delivery for HIV treatment seeks to enhance medication adherence while respecting the preferences of people living with HIV. Nevertheless, patients’ experiences of using these differentiated service delivery models or approaches have not been qualitatively compared. Underpinned by the tenets of descriptive phenomenology, we e...
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Citations
... A study in Eswatini found that 96% of study participants were satisfied with their current ART delivery model, and 90% recommended it to others [17]. Recipients of care from Khayelitsha in Cape Town, South Africa, also reported generally positive experiences with DSD model care [27], and 64.2% of those enrolled in DSD model care in Uganda reported high satisfaction with the treatment [18]. These prior studies did not compare satisfaction with DSD model care with conventional care [17,18,28]. ...
... They reported shorter waiting times and quicker service delivery, especially among those collecting their treatment at external pick-up points. Convenient and accelerated service delivery are considered important drivers of service utilization [27]. DSD enrolees also lauded this aspect of health service delivery in DSD models in Khayelitsha, Cape Town and Eswatini [17,28]. ...
Introduction
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.
Methods
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.
Results
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.
Conclusions
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.
... Similar studies have shown that adherence rates were higher in groups where clients were involved in the distribution and administration of ART drugs than in those where healthcare providers were responsible for the entire process. 8,15,16 In low-resource settings, where access to healthcare is limited, community-led ART delivery groups can provide a supportive environment for PLHIV and improve their overall health outcomes. Being part of a supportive community can positively influence health, adherence to ART, and overall health outcomes of people living with HIV (PLHIV). ...
Background:
Community client-led ART delivery groups (CCLADs) were introduced as one of the strategies to better serve individual needs and reduce unnecessary burdens on the health system. However, limited data adequately explained the factors influencing ART adherence among HIV/AIDS patients in CCLAD's model of care. The study aimed to assess the factors influencing ART adherence among HIV-positive patients attending CCLADs in Lira District, Uganda.
Materials and methods:
We employed a qualitative method of data collection recruiting 25 study participants (expert clients) between July and August 2020. The study purposefully chose 25 participants to participate in with HIV/AIDS patients enrolled in community-based HIV care models. The interviews were recorded on audiotape, transcribed, and translated verbatim. We used a thematic approach to analyze the data.
Results:
Our study shows that social support among group members, patient self-motivation, counselling, and guidance were the major facilitators of adherence. From the analysis of results, our study found the following themes: Lack of food, stigma, forgetfulness, stress, unfair staff at the hospital, and socio-cultural beliefs were among the major barriers identified in this study.
Conclusion:
The study emphasizes that CCLADs improve ART adherence for HIV-positive clients by providing a supportive environment and medication access. Peer influence on alternative medicine usage hinders adherence. We recommend that continued support, funding, and education are necessary to address misconceptions and sustain CCLADs' effectiveness.
... DSD encompasses different strategies including offering HIV services in the community or facility, and task-shifting from physicians or nurses to other types of health providers including community health workers (CHWs) [16][17][18]. Evidence suggests that DSD models are comparable to standard of care for clinical outcomes and improve patient satisfaction [16,19]. ...
Novel community-based approaches are needed to achieve and sustain HIV epidemic control in Zambia. Under the Stop Mother and Child HIV Transmission (SMACHT) project, the Community HIV Epidemic Control (CHEC) differentiated service delivery model used community health workers to support HIV testing, ART linkage, viral suppression, and prevention of mother-to-child transmission (MTCT). A multi-methods assessment included programmatic data analysis from April 2015 to September 2020, and qualitative interviews from February to March 2020. CHEC provided HIV testing services to 1,379,387 clients; 46,138 were newly identified as HIV-positive (3.3% yield), with 41,366 (90%) linked to ART. By 2020, 91% (60,694/66,841) of clients on ART were virally suppressed. Qualitatively, healthcare workers and clients benefitted from CHEC, with provision of confidential services, health facility decongestion, and increased HIV care uptake and retention. Community-based models can increase uptake of HIV testing and linkage to care, and help achieve epidemic control and elimination of MTCT.
... Roll out of the five DMOC types may have offered many patients some flexibility in choosing a model that better meets their needs. Other studies in South Africa shown that patients were offered an opportunity to choose a preferred DMOC model [52,53]. Despite increased access to PuP and SFLA, many eligible patients in our setting opted to continue with AC or community groups. ...
Differentiated models of HIV care (DMOC) aim to improve health care efficiency. We describe outcomes of five DMOC in KwaZulu-Natal, South Africa: facility adherence clubs (facility AC) and community adherence clubs (community AC), community antiretroviral treatment (ART) groups (CAG), spaced fast lane appointments (SFLA), and community pick up points (PuP). This retrospective cohort study included 8241 eligible patients enrolled into DMOC between 1/1/2012 and 31/12/2018. We assessed retention in DMOC and on ART, and viral load suppression (<1000 copies/mL). Kaplan-Meier techniques were applied to describe crude retention. Mixed effects parametric survival models with Weibull distribution and clustering on health center and individual levels were used to assess predictors for ART and DMOC attrition, and VL rebound (≥1000 copies/mL). Overall DMOC retention was 85%, 80%, and 76% at 12, 24 and 36 months. ART retention at 12, 24 and 36 months was 96%, 93%, 90%. Overall incidence rate of VL rebound was 1.9 episodes per 100 person-years. VL rebound rate was 4.9 episodes per 100 person-years among those enrolled in 2012–2015, and 0.8 episodes per 100 person-years among those enrolled in 2016–2018 (RR 0.12; 95% CI, 0.09–0.15, p<0.001). Prevalence of confirmed virological failure was 0.6% (38/6113). Predictors of attrition from DMOC and from ART were male gender, younger age, shorter duration on ART before enrollment. Low level viremia (>200–399 copies/mL) was associated with higher hazards of VL rebound and attrition from ART. Concurrent implementation of several DMOC in a large ART program is feasible and can achieve sustained retention on ART and VL suppression.
... The eight additional studies found that the delivery of ART services at private pharmacies was largely feasible and acceptable [48][49][50][51][52][53][54][55]. Three pilot studies in Uganda and Nigeria that assessed the feasibility of pharmacy-delivered ART refills found that the majority (>90%) of ART clients chose this option and refilled on schedule [49,51,56]. ...
... An analysis of in-depth interviews with stakeholders in South Africa reported that private pharmacies were an instrumental and underexplored component of differentiated HIV service delivery [50]. In acceptability studies in South Africa and Botswana, ART clients reported that they would be willing to pay for pharmacy-delivered ART refills [57], most found these services to be quicker and more convenient than clinicdelivered refills [53], and many indicated that this model fit their values, preferences and needs [55]. However, some clients were concerned with inadvertent disclosure of their HIV status when pharmacy providers refill ART [53] and potentially lower-quality communication, education and emotional support received with the delivery of ART refills at pharmacies versus clinics [55]. ...
... In acceptability studies in South Africa and Botswana, ART clients reported that they would be willing to pay for pharmacy-delivered ART refills [57], most found these services to be quicker and more convenient than clinicdelivered refills [53], and many indicated that this model fit their values, preferences and needs [55]. However, some clients were concerned with inadvertent disclosure of their HIV status when pharmacy providers refill ART [53] and potentially lower-quality communication, education and emotional support received with the delivery of ART refills at pharmacies versus clinics [55]. ...
Introduction:
Private pharmacies are an understudied setting for differentiated delivery of HIV services that may address barriers to clinic-delivered services, such as stigma and long wait times. To understand the potential for pharmacy-delivered HIV services in sub-Saharan Africa, we conducted a scoping review of the published and grey literature.
Methods:
Using a modified Cochrane approach, we searched electronic databases through March 2022 and HIV conference abstracts in the past 5 years for studies that: (1) focused on the delivery of HIV testing, antiretroviral therapy (ART) and/or pre-exposure prophylaxis (PrEP) at private pharmacies in sub-Saharan Africa; (2) reported on effectiveness outcomes (e.g. HIV incidence) or implementation outcomes, specifically feasibility and/or acceptability; and (3) were published in English. Two authors identified studies and extracted data on study setting, population, design, outcomes and findings by HIV service type.
Results and discussion:
Our search identified 1646 studies. After screening and review, we included 28 studies: seven on HIV testing, nine on ART delivery and 12 on PrEP delivery. Most studies (n = 16) were conducted in East Africa, primarily in Kenya. Only two studies evaluated effectiveness outcomes; the majority (n = 26) reported on feasibility and/or acceptability outcomes. The limited effectiveness data (n = 2 randomized trials) suggest that pharmacy-delivered HIV services can increase demand and result in comparable clinical outcomes (e.g. viral load suppression) to standard-of-care clinic-based models. Studies assessing implementation outcomes found actual and hypothetical models of pharmacy-delivered HIV services to be largely feasible (e.g. high initiation and continuation) and acceptable (e.g. preferable to facility-based models and high willingness to pay/provide) among stakeholders, providers and clients. Potential barriers to implementation included a lack of pharmacy provider training on HIV service delivery, costs to clients and providers, and perceived low quality of care.
Conclusions:
The current evidence suggests that pharmacy-delivered HIV services may be feasible to implement and acceptable to clients and providers in parts of sub-Saharan Africa. However, limited evidence outside East Africa exists, as does limited evidence on the effectiveness of and costs associated with pharmacy-delivered HIV services. More research of this nature is needed to inform the scale-up of this new differentiated service delivery model throughout the region.
... All these barriers hinder ALWHIV from keeping scheduled appointments. Literature elsewhere concurred with these ndings (Mukumbang et al., 2022). ...
Background: Differentiated service delivery model such as Community Drug Distribution Points (CDDPs) was adopted by Uganda as one of the strategies to decongest the HIV clinics as well as decentralizing HIV care services closer to the stable clients with undetectable viral load. Despite the creation of CDDPs in the catchment areas of accredited anti-retroviral therapy clinics, its utilization remains low at 25%. However, there is little information on the barriers and facilitators to the utilization of CDDPs among adolescents aged 10 to19 years living with HIV in Uganda. The aim of this study was to explore the barriers and facilitators to utilization of CDDPs among Adolescent Living With HIV (ALWHIV) aged 10-19 years in Lira District, Northern Uganda.
Methods: We conducted an exploratory descriptive study. A total of 29 qualitative interviews were conducted. Participants were purposively selected. Categories of participants included adolescents aged 10 to19 years living with HIV, caregivers of minors, and lay health care workers at the selected CDDPs. Data was collected using in-depth interviews, focus group discussions and key informant interviews. Data was audio recorded, transcribed and coded manually in which the codes were agreed upon by the authors of the study. The coded data was summarized into major themes on a matrix using master sheet analysis technique. Thematic content analysis was done, the findings were narrated verbatim and presented as text quotes.
Results: Our data shows a number of barriers to utilization of CDDPs among ALWHIV in rural settings. Barriers were categorized as individual level (limited level of privacy, fears and worries, long waiting hours and distance), family related (insults and heavy work load) and health system related (lack of transport). Major facilitators to utilization of CDDPs included ease of access to ART care services, shorter waiting time, desires to remain healthy and productive, and peer support and group encouragement.
Conclusion and recommendations: Our study adds important public health evidence that CDDPs, as one of the community-based models, seems to be serving underprivileged population with low level of education. We recommend provision of appropriate infrastructures used as CDDPs to protect clients’ privacy and confidentiality. ALWHIV need to be served as individuals on arrival as members of the groups at the CDDPs. There is need to strengthen community engagement and sensitization to eliminate HIV related stigma experienced by ALWHIV.
We conducted qualitative research among people with HIV (PWH) and care providers in Cape Town, South Africa to understand the impact of negative clinic experiences on adherence and support preferences. In-depth interviews were conducted with 41 patients with an unsuppressed viral load or a treatment gap, and focus group discussions with physicians, nurses, counselors, and community health workers. Questions addressed treatment history and adherence barriers, then participants evaluated evidence-based adherence interventions for potential scale up. Inductive analysis examined care experiences and corresponding preference for intervention options. More than half of PWH described negative experiences during clinic visits, including mistreatment by staff and clinic administration issues, and these statements were corroborated by providers. Those with negative experiences in care stated that fear of mistreatment led to nonadherence. Most patients with negative experiences preferred peer support groups or check-in texts to clinic-based interventions. We found that PWH's negative clinic experiences were a primary reason behind nonadherence and influenced preferences for support mechanisms. These findings emphasize the importance of HIV treatment adherence interventions at multiple levels both in and outside of the clinic, and providing more comprehensive training to providers to better serve PWH in adherence counseling, especially those who are most vulnerable..
