Differentiated Antiretroviral Therapy Delivery: Implementation Barriers and Enablers in South Africa

Abstract

Scale-up of antiretroviral therapy (ART) for people living with HIV requires differentiated models of ART delivery to improve access and contribute to achieving viral suppression for 95% of people on ART. We examined barriers and enablers in South Africa via semistructured interviews with 33 respondents (program implementers, nurses, and other health care providers) from 11 organizations. The interviews were recorded, transcribed, and analyzed for emerging themes using NVivo 11 software. Major enablers of ART delivery included model flexibility, provision of standardized guidance, and an increased focus on person-centered care. Major barriers were related to financial, human, and space resources and the need for time to allow buy-in. Stigma emerged as both a barrier and an enabler. Findings suggest that creating and strengthening models that cater to client needs can achieve better health outcomes. South Africa's efforts can inform emerging models in other settings to achieve epidemic control.

Investigating the implementation of differentiated HIV services and implications for pregnant and postpartum women: A mixed methods multi-country study

“…Further research is merited to explore these issues in this setting. A reluctance to use fast-track queues by patients may be attributed to some clients still preferring to receive regular HIV care in clinical settings where they have established nurse/client relationships, receive regular health screening and can connect to other clients despite waiting and spending more time at the clinic (Sharer et al, 2019). Research from elsewhere in South Africa has also shown that post-partum women may avoid differentiated models of care if they are not in close proximity to health services for their infants (Myer et al, 2017).…”

Provider‐ and patient‐level costs associated with providing antiretroviral therapy during the postpartum phase to women living with HIV in South Africa: A cost comparison of three postpartum models of care

“…For those eligible and attending a CAC, the less frequent visit requirement of CACs (see Table 1) and ability to send a treatment 'buddy' to collect ART may aid WLH who are working or who would be unable to come to the clinic as regularly [40]. This flexibility is appreciated by those in CACs [8,40]. Integrated Care has the benefit of prolonging the time that the mother-infant pair are kept together which may limit (at least initially) the loss to follow up during transfer to another model [41].…”

“…The International AIDS (acquired immunodeficiency syndrome) Society categorises ART service delivery into four main types: 'facility-based individual models'; 'out-of-facility individual models'; 'healthcare worker-managed groups'; and 'clientmanaged groups' [6,7]. Some examples of specific ART delivery models within these four broad categories are as follows: fast track systems for ART collection within clinics such as in Malawi; community pharmacy collection in Nigeria; pick up points outside of healthcare facilities in the Democratic Republic of the Congo; collection by family members in Zimbabwe; teen ART clubs in Malawi and Swaziland; community adherence clubs in South Africa; and ART care integrated with other healthcare services such as for depression as is being studied in Malawi and Zimbabwe [6,[8][9][10][11][12][13][14]. WHO and UNICEF particularly recommend supporting the adherence of mothers during the postpartum period as part of the third and fourth part, of a four-component strategic approach to the prevention of mother-to-child transmission of HIV (PMTCT) [15,16].…”

“…Multiple limiting and enabling factors have been found to assist successful delivery of ART. Identified enablers from a qualitative study in South Africa are care being focused on the patient and clear support and guidance from the National Department of Health, which aids the adoption of context-specific models of care which in turn facilitate flexibility for patients [8]. Barriers include stigma and discrimination and lack of resources (such as physical space and personnel capacity due to their high workload and staff turnover) [8,17].…”

OUP accepted manuscript

“…(2018 , 2019a , 2019b) have published a significant body of work on the programme theories underlying the ‘adherence club’ intervention, exploring how this intervention mitigates the relationship clients have with the health service and their treatment. Research by Bell et al (2019) explores men’s life context and how both the psychological and practical aspects of this context affects their access to HIV testing and treatment, and a study by Sharer et al (2019) discusses how codification of the 2016 National Adherence Guidelines by health services enabled HIV care that was flexible and which thereby facilitated differentiated, client-centred care.…”