HIV stigma may prevent people from obtaining a timely diagnosis and engaging in life-saving care. It may also prevent those who are HIV infected from seeking health and education resources, particularly if they are from marginalized communities. We inductively explored the roots of stigma and its impact on health services and resource seeking as experienced by HIV-infected members of marginalized communities in Vancouver, British Columbia, Canada, using a community-based participatory research framework. Five peer-facilitated focus groups were conducted with 33 Aboriginal, Latino, Asian, and African participants. Thematic analysis of the experiences revealed four dominant themes: beginnings of stigma, tensions related to disclosure, experiences of service seeking, and beyond HIV stigma and discrimination. Persons living with HIV from Aboriginal and refugee communities continue to experience disproportionate rates of stigma and discrimination. Fear remains a prime obstacle influencing these groups' abilities and willingness to access care in various settings.

IntroductionIncreasing access to multi‐month dispensing (MMD) of antiretroviral therapy (ART) supports treatment continuity and viral load suppression for people living with HIV (PLHIV) and reduces burden on health facilities. During the COVID‐19 response, PEPFAR worked with ministries of health to scale up MMD and expand eligibility to new groups of PLHIV, including children and pregnant/breastfeeding women. We analysed PEPFAR program data to understand the impact of the policy changes on actual practice.MethodsWe conducted a desk review in 21 PEPFAR‐supported countries to identify and collect official documentation released between March and June 2020 addressing changes to MMD guidance during the COVID‐19 response. MMD coverage, the proportion of all ART clients on MMD, was assessed in the calendar quarters preceding the COVID‐19 response (Q4 2019, October–December 2019; and Q1, January–March 2020) and the quarters following the start of the response (Q2 2020, April–June 2020; Q3 2020, July–September, 2020; Q4 2020, October–December 2020). We used the two‐proportion Z‐test to test for differences in MMD coverage pre‐COVID‐19 (Q4 2019) and during implementation of COVID‐19 policy adaptations (Q2 2020).Results and discussionAs of June 2020, 16 of the 21 PEPFAR‐supported countries analysed adapted MMD policy or promoted intensified scale‐up of MMD in response to COVID‐19. MMD coverage for all clients on ART grew from 49% in Q4 2019 pre‐COVID‐19 to 72% in Q2 2020 during COVID‐19; among paediatric clients (< 15), MMD coverage increased from 27% to 51% in the same period. Adaptations to MMD policy were associated with a significantly accelerated growth in the proportion of clients on MMD (p < 0.001) for all populations, irrespective of age and dispensing interval.ConclusionsAccess to MMD markedly expanded during the COVID‐19 pandemic, supporting treatment continuity while mitigating exposure to COVID‐19 at health facilities. This model is beneficial in public health emergencies and during disruptions to the healthcare system. Outside emergency contexts, expanded MMD eligibility extends client‐centred care to previously excluded populations. The success in expanding MMD access during COVID‐19 should motivate countries to recommend broader MMD access as a new standard of care.

Background The World Health Organization (WHO) and the Uganda Ministry of Health recommend differentiated service delivery models (DSDMs) as patient-centered antiretroviral therapy (ART) mechanisms for people living with HIV/AIDS (PLHIV) with undetectable viral loads. We studied patient satisfaction with ART services, and its associated factors amongst PLHIV enrolled in DSDMs in Uganda. Methods This cross-sectional study involved a random sample of PLHIV accessing DSDM-related ART at nine facilities in East Central Uganda. Eligible patients were adult PLHIV (≥18 years), on ART, and enrolled for at least 12 months in one of three DSDMs: Community Client-Led ART Delivery (CCLAD), Community Drug Distribution Points (CDDP), or Fast-Track Drug Refill (FTDR). We collected data from June to July 2019. A validated tool measured satisfaction. General Estimating Equations with modified Poisson regression and exchangeable correlation structures accounted for clustering at health facilities and identified DSDM-related satisfaction factors. Results Of 842 participants enrolled, 530 (63.5%) accessed HIV care through CDDP, 166 (20.1%) through CCLAD, and 146 (16.3%) through FTDR; 541 (64.2%) were satisfied with DSDM services: 78.7% in CDDP, 42.8% in CCLAD, and 36.3% in FTDR. The delivery and treatment factors positively associated with satisfaction included: being enrolled on CDDP [adjusted prevalence ratio (aPR) = 1.51, 95% CI:1.47–1.56] or FTDR [aPR = 1.47, 95% CI:1.26–1.71] relative to CCLAD and being enrolled in a DSDM for more than 3 years [aPR = 1.28, 95% CI:1.11–1.48]. Poor ART adherence [aPR = 0.33, 95% CI:0.19–0.56] and having a baseline WHO HIV stage of 3 or 4 [aPR = 0.36, 95% CI:0.20–0.64] relative to stages 1 and 2 were negatively associated. Among socioeconomic factors, having lower transport costs (< $1.35) per clinic visit [aPR = 1.34, 95% CI:1.17–1.53], being employed [aPR = 1.61, 95% CI:1.38–1.87], and being single [aPR = 1.10, 95% CI:1.08–1.13] were positively associated with satisfaction; drinking alcohol at least once a week [aPR = 0.77, 95% CI:0.63–0.93] was negatively associated with patient satisfaction. Conclusions Results showed that 64.2% of patients were satisfied with DSDM services. HIV service delivery and treatment factors (DSDM type, time in DSDM, WHO stage, ART adherence), plus social factors (employment and marital status, transport costs, alcohol consumption), were associated with patient satisfaction. DSDM implementers should tailor services to address these factors to improve patient satisfaction.

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Background The World Health Organization and Uganda Ministry of Health recommend differentiated service delivery models (DSDM) as patient-focussed approaches for delivering antiretroviral therapy for people living with HIV/AIDS (PLHIV) who have undetectable viral loads. We sought to determine the factors significantly associated with patient satisfaction with ART services amongst PLHIV enrolled in DSDMs. Methods This was a cross-sectional study of a random sample of PLHIVs accessing ART within DSDMs at nine facilities in East Central Uganda. Eligible patients were adult PLHIVs active on ART and enrolled in a DSDM (Community Client Led ART Delivery (CCLAD), Community Drug Distribution Points (CDDP) and Fast-Track Drug Refill (FTDR) models) for at-least twelve months. Data was collected over two months (June-July 2019). A validated tool was used to assess PLHIV satisfaction with service delivery in DSD. Logistic regression was used to establish factors associated with patient satisfaction with DSD services. Results Overall out of the 842 participants enrolled onto the study, 530(63.5%) accessed HIV care through CDDPs, 166(20.1%) through CCLAD, and 146 (16.3%) through FTDR DSDMs. Generally, 541 (64.2%) were satisfied with DSDM services : 78.7% in CDDP, 42.8% in CCLAD and 36.3% in CCLAD. The factors associated with patient satisfaction were being on CDDP [aOR = 3.42, 95% CI = 2.15–5.44] and FTDR[aOR = 2.92, 95% CI = 1.34–6.31] DSDMs relative to CCLAD, greater than three years on DSDM [aOR = 2.32, 95% CI = 1.12–4.87], lower transport costs (< $ 1.35) per clinic visit [aOR = 2.39, 95% CI = 1.59–3.60] being employed either in agriculture[aOR = 4.41, 95% CI = 2.62–7.41] or any other employment sector [aOR = 4.22, 95% CI = 2.46–7.27]relative to being unemployed, participation of a friend/relative [aOR = 1.79, 95% CI = 1.22–2.61] and not drinking alcohol [aOR = 2.33, 95% CI = 1.24–4.29]. Conclusions The study highlighted that 64.2% of the patients are satisfied with services in DSDM. Service delivery factors (DSDM model type, time spent in DSDM, and having friend or relative enrolled at the ART point providing social support), social factors (employment, and alcohol consumption), and transport costs were all associated with patient satisfaction with DSDM. Implementers of DSDMs need to further adapt services to address these factors to improve patient satisfaction in DSDMs.