Differentiated service delivery (DSD) models for HIV treatment in Malawi, South Africa, and Zambia can be grouped into 12 service delivery strategies that vary by population served, medication dispensing duration, location of medication delivery, frequency of health care system interactions, and other characteristics.n As of 2019, most DSD models in Malawi, South Africa, and Zambia remained limited to clinically stable, adult patients and continue to depend on established facilities for clinical care; individual models relied more on clinical staff, while group models made greater use of lay personnel. n DSD models required anywhere from 2 to 12 health care system interactions per year, imposing very different burdens on patients and clinics.
IntroductionDifferentiated service delivery (DSD) models aim to improve the access of human immunodeficiency virus treatment on clients and reduce requirements for facility visits by extending dispensing intervals. With the advent of the COVID‐19 pandemic, minimising client contact with healthcare facilities and other clients, while maintaining treatment continuity and avoiding loss to care, has become more urgent, resulting in efforts to increase DSD uptake. We assessed the extent to which DSD coverage and antiretroviral treatment (ART) dispensing intervals have changed during the COVID‐19 pandemic in Zambia.MethodsWe used client data from Zambia's electronic medical record system (SmartCare) for 737 health facilities, representing about three‐fourths of all ART clients nationally. We compared the numbers and proportional distributions of clients enrolled in DSD models in the 6 months before and 6 months after the first case of COVID‐19 was diagnosed in Zambia in March 2020. Segmented linear regression was used to determine whether the outbreak of COVID‐19 in Zambia further accelerated the increase in DSD scale‐up.Results and discussionBetween September 2019 and August 2020, 181,317 clients aged 15 or older (81,520 and 99,797 from 1 September 2019 to 1 March 2020 and from 1 March to 31 August 2020, respectively) enrolled in DSD models in Zambia. Overall participation in all DSD models increased over the study period, but uptake varied by model. The rate of acceleration increased in the second period for home ART delivery (152%), 2‐month fast‐track (143%) and 3‐month MMD (139%). There was a significant reduction in the enrolment rates for 4‐ to 6‐month fast‐track (−28%) and “other“ models (−19%).ConclusionsParticipation in DSD models for stable ART clients in Zambia increased after the advent of COVID‐19, but dispensing intervals diminished. Eliminating obstacles to longer dispensing intervals, including those related to supply chain management, should be prioritized to achieve the expected benefits of DSD models and minimize COVID‐19 risk.
Introduction: Many countries in Africa are scaling up differentiated service delivery (DSD) models for HIV treatment, but most existing data systems do not describe the models in use. We surveyed organizations that were supporting DSD models in 2019 in Malawi, South Africa, and Zambia to describe the diversity of DSD models being implemented at that time. Methods: We interviewed DSD model implementing organizations for descriptive information about each model of care supported by the organization. We described the key characteristics of each model, including population of patients served, location of service delivery, frequency of interactions with patients, duration of dispensing, and cadre(s) of provider involved. To facilitate analysis, we refer to one organization supporting one model of care as an organization-model. Results: The 34 respondents (8 in Malawi, 16 in South Africa, 10 in Zambia) interviewed described a total of 110 organization-models, which included 19 facility based individual models, 21 out-of-facility based individual models, 14 healthcare worker led groups, and 3 client led groups; jointly, these encompassed 12 service delivery strategies. Over 2/3 (n=78) of the organization-models were limited to clinically stable patients. Almost all organization-models (n=96) continued to provide clinical care at established healthcare facilities; medication pickup took place at facilities, external pickup points, and adherence clubs. Required numbers of provider interactions per year varied widely, from a low of 2 to a high of 12. Dispensing intervals were typically 3 or 6 months in Malawi and Zambia and 2 months in South Africa. Individual models relied more on clinical staff (doctors, nurses, pharmacists), while group models made greater use of lay personnel (community health workers, counselors). Conclusions: As of 2019, there was a large variety of differentiated service models being offered for HIV treatment in Malawi, South Africa, and Zambia, serving diverse patient populations.
Background: Differentiated service delivery (DSD) models aim to lessen the burden of HIV treatment on patients and providers in part by reducing requirements for facility visits and extending dispensing intervals. With the advent of the COVID-19 pandemic, minimizing patient contact with healthcare facilities and other patients, while maintaining treatment continuity and avoiding loss to care, has become more urgent, resulting in efforts to increase DSD uptake. We assessed the extent to which DSD coverage and antiretroviral treatment (ART) dispensing intervals have changed during the COVID-19 pandemic in Zambia. Methods: We used patient data from Zambia's electronic medical record system (SmartCare) for 737 health facilities, representing about 3/4 of all ART patients nationally, to compare the numbers and proportional distributions of patients enrolled in DSD models in the six months before and six months after the first case of COVID-19 was diagnosed in Zambia in March 2020. Segmented linear regression was used to determine whether the introduction of COVID-19 into Zambia further accelerated the increase in DSD scale-up. Results: Between September 2019 and August 2020, 181,317 patients aged 15+ (81,520 and 99,797 from September 1, 2019 to March 1, 2020 and from March 1 to August 31, 2020, respectively) enrolled in DSD models in Zambia. Overall participation in all DSD models increased over the study period, but uptake varied by model. The rate of acceleration increased in the second period for home ART delivery (152%), 0-2-month fast-track (143%), and 3-month MMD (139%). There were significant decelerations in the increase in enrolment for 4-6-month fast-track (-28%) and 'other' models (-19%). Conclusions: Participation in DSD models for stable ART patients in Zambia increased after the advent of COVID-19, but dispensing intervals diminished. Eliminating obstacles to longer dispensing intervals, including those related to supply chain management, should be prioritized to achieve the expected benefits of DSD models and minimize COVID-19 risk.
Background: Most differentiated service delivery (DSD) models for HIV treatment, which are intended to improve ART programme outcomes, require that a patient have spent >6 or >12 months on antiretroviral treatment (ART) ART for eligibility. Attrition from ART programmes, however, is highest among those newly initiated and thus ineligible for DSD models. Because some patients are enrolled "early", prior to 6 or 12 months on ART, we were able to evaluate loss to follow-up among patients in Zambia enrolled in DSD models after differing intervals on ART. Methods: Data were extracted from electronic medical records of patients (>15 years) enrolled in DSD models from October 2019-March 2020. We compared 12-month loss to follow-up (LTFU), defined as "lost to follow-up", "inactive", or "stopped ART" at 9-15 months after DSD enrolment, among patients enrolled in six DSD models after <6 months, 6-12 months, and >12 months on ART, with those enrolled with <6 or <12 months on ART termed "early enrollers" and those enrolled with >12 months termed "established". We adjusted for age, sex, urban/rural status, and duration of ART dispensing. Results: Of 88,556 patients enrolled in a DSD model, 4% (n=3,143) and 8% (n=6,714) had initiated ART <6 months or 6-12 months before DSD entry, respectively. Early enrollers were less likely to be LTFU at 12 months than established patients (adjusted risk ratio (aRR) [95% confidence interval] for <6 months on ART 0.72 [0.62-0.83]; aRR 0.74 [0.67-0.82] for 6-12 months on ART) for almost all DSD models and dispensing durations. A limitation of the analysis is that early enrollers may have been selected for DSD participation due to providers' expectations about future retention. Conclusions: Patients enrolled in DSD models in Zambia after less than a year on ART were more likely to be retained in care 12 months later than were patients established on ART at DSD enrollment. Offering enrollment to at least some newly-initiating ART patients may improve ART programme outcomes.
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