Differentiated service delivery: a qualitative study of people living with HIV and accessing care in a tertiary facility in Ghana

Abstract

BackgroundIn 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) set out a treatment target with the objective to help end the AIDS epidemic by 2030. This was supported by the UNAIDS ’90-90-90’ target that by 2020, 90% of all people living with HIV (PLHIV) will know their HIV status; 90% of all those diagnosed with HIV will be on sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will have viral suppression. The concept of offering differentiated care services using community-based models is evidence-based and is suggested as a means to bring this target into reality. This study sought to explore the possible predictors and acceptability of Community-based health service provision among PLHIV accessing ART services at the Cape Coast Teaching Hospital (CCTH) in Ghana.MethodsA qualitative study, using 5 focus group discussions (FGD) of 8 participants per group, was conducted at the HIV Clinic in CCTH, in the Central Region of Ghana. Facilitators administered open-ended topic-guided questions. Answers were audio recorded, later transcribed and combined with notes taken during the discussions. Themes around Facility-based and Community-based service delivery and sub-themes developed from the codes, were verified and analyzed by the authors, with the group as the unit for analysis.ResultsParticipants expressed preference for facility–based service provision with the construct that, it ensures comprehensive health checks before provision of necessary medications. PLHIV in this study wished that the facility-based visits be more streamlined so “stable clients” could visit twice in a year to reduce the associated time and financial cost. The main barrier to community-based service delivery was concerns about stigmatization and abandonment in the community upon inadvertent disclosure of status.ConclusionsAlthough existing evidence suggests that facility-based care was relatively more expensive and time consuming, PLHIV preferred facility-based individualized differentiated model to a community-based model. The fear of stigma and discrimination was very strong and is the main barrier to community-based model among PLHIV in this study and this needs to be explored further and managed.

Understanding implementation barriers in the national scale-up of Differentiated ART delivery in Uganda

“…Contrary to what has been reported in the literature about the benefits realized by patients such as savings in transport costs and time spent at facilities via DSD when compared to more intensive undifferentiated care models [14], [18], [30], [32] our findings suggest that the picture is more complex and patients have other considerations in the models of HIV care they prefer. For instance, some patients in our study sample, preferred frequent clinic visits with a few expressing a willingness to spend money and time despite awareness of the benefits of DSD in reducing the burden of treatment.…”

“…Although DSD has been rolled-out nationally in several countries since WHO's landmark 2016 guidelines were released, there is a dearth of evidence on patient perspectives on HIV care under DSD in 'real world' settings or at the frontline level of service delivery [15]- [17]. A notable exception is a study conducted in Ghana [18]. However, that study only reported patient experiences of DSD from one tertiary hospital in Cape Coast Ghana.…”

Family–Based Index Testing for HIV: a qualitative study of barriers and challenges among clients in Cape Coast, Ghana

“…This aligns with other studies where home counseling and testing was considered as one of the most effective strategies to reach more people [17] and attend to family preference for home counseling and testing due to issues of privacy and con dentiality [4,18,19]. In contrast a study among people living with HIV in this same setting had revealed a fear of accidental disclosure associated with communitybased service provision [20]. This is an indication that there is no conclusive evidence of home -based testing being the preferred option over facility-based service.…”

A Qualitative Assessment of Provider and Client Experiences With 3- and 6-Month Dispensing Intervals of Antiretroviral Therapy in Malawi

“…A study evaluating the impact of spaced clinic appointments for clients with HIV (6 months versus 1 month) found that 30% were removed from 6-month dispensing due to having unstable medical conditions such as decreased CD4 counts, ART regimen changes, pregnancy, nonadherence, and drug toxicity. 22 If 6-month dispensing is taken to scale, clients should be counseled about coming to the ART clinic without delay for any new health issues. Providers should receive appropriate training about when to shift clients to shorter intervals due to poor adherence/virologic failure, side effects, after regimen changes, or during pregnancy.…”