Differentiated Service Delivery Models for HIV Treatment in Malawi, South Africa, and Zambia: A Landscape Analysis

Huber, Amy; Pascoe, Sophie; Nichols, Brooke E; Long, Lawrence; Kuchukhidze, Salome; Phiri, Bevis; Tchereni, Timothy; Rosen, Sydney

doi:10.9745/ghsp-d-20-00532

Cited by 32 publications

(32 citation statements)

References 13 publications

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“…For people living with HIV (PLWH) in low- and middle-income countries (LMICs) and on antiretroviral treatment (ART), unnecessary clinic and pharmacy appointments impose an avoidable burden on both patients and providers. Efforts to decrease the frequency of unneeded contact with the health system represent a central pillar of the movement toward differentiated service delivery (DSD) models [ 1 , 2 ]. There is, however, concern that reduced frequency might also compromise meaningful clinical and psychosocial interactions with the health system and potentially, paradoxically, increase missed appointments or non-adherence over the long term.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of HIV treatment outcomes with reduced frequency of clinical encounters and antiretroviral treatment refills: A systematic review and meta-analysis

et al. 2022

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Background Global HIV treatment programs have sought to lengthen the interval between clinical encounters for people living with HIV (PLWH) who are established on antiretroviral treatment (ART) to reduce the burden of seeking care and to decongest health facilities. The overall effect of reduced visit frequency on HIV treatment outcomes is however unknown. We conducted a systematic review and meta-analysis to evaluate the effect of implementation strategies that reduce the frequency of clinical appointments and ART refills for PLWH established on ART. Methods and findings We searched databases between 1 January 2010 and 9 November 2021 to identify randomized controlled trials (RCTs) and observational studies that compared reduced (6- to 12-monthly) clinical consultation or ART refill appointment frequency to 3- to 6-monthly appointments for patients established on ART. We assessed methodological quality and real-world relevance, and used Mantel–Haenszel methods to generate pooled risk ratios (RRs) with 95% confidence intervals for retention, viral suppression, and mortality. We evaluated heterogeneity quantitatively and qualitatively, and overall evidence certainty using GRADE. Searches yielded 3,955 records, resulting in 10 studies (6 RCTs, 3 observational studies, and 1 study contributing observational and RCT data) representing 15 intervention arms with 33,599 adults (≥16 years) in 8 sub-Saharan African countries. Reduced frequency clinical consultations occurred at health facilities, while reduced frequency ART refills were delivered through facility or community pharmacies and adherence groups. Studies were highly pragmatic, except for some study settings and resources used in RCTs. Among studies comparing reduced clinical consultation frequency (6- or 12-monthly) to 3-monthly consultations, there appeared to be no difference in retention (RR 1.01, 95% CI 0.97–1.04, p = 0.682, 8 studies, low certainty), and this finding was consistent across 6- and 12-monthly consultation intervals and delivery strategies. Viral suppression effect estimates were markedly influenced by under-ascertainment of viral load outcomes in intervention arms, resulting in inconclusive evidence (RR 0.74, 95% CI 0.59–0.94, p = 0.015, 4 RCTs, very low certainty). There was similarly insufficient evidence to draw conclusions on mortality (RR 1.12, 95% CI 0.75–1.66, p = 0.592, 6 studies, very low certainty). For ART refill frequency, there appeared to be little to no difference in retention (RR 1.01, 95% CI 0.98–1.06, p = 0.473, 4 RCTs, moderate certainty) or mortality (RR 1.45, 95% CI 0.63–3.35, p = 0.382, 4 RCTs, low certainty) between 6-monthly and 3-monthly visits. Similar to the analysis for clinical consultations, no conclusions could be drawn on viral suppression (RR 0.60, 95% CI 0.41–0.88, p = 0.009, 3 RCTs, very low certainty). This systematic review was limited by the small number of studies available to compare 12- versus 6-monthly clinical consultations, insufficient data to compare implementation strategies, and lack of evidence for children, key populations, and low- and middle-income countries outside of sub-Saharan Africa. Conclusions Based on this synthesis, extending clinical consultation intervals to 6 or 12 months and ART dispensing intervals to 6 months appears to result in similar retention to 3-month intervals, with less robust conclusions for viral suppression and mortality. Future research should ensure complete viral load outcome ascertainment, as well as explore mechanisms of effect, outcomes in other populations, and optimum delivery and monitoring strategies to ensure widespread applicability.

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Section: Introductionmentioning

confidence: 99%

Evaluation of HIV treatment outcomes with reduced frequency of clinical encounters and antiretroviral treatment refills: A systematic review and meta-analysis

et al. 2022

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“…To date, community-based and out-of-facility care models have been applied to scale up treatment for HIV and tuberculosis (TB), with different success [ 29 – 35 ]. However, currently, there is no consensus nor guidance on how such models should be structured to have substantial impact in aHT care.…”

Section: Background and Aimmentioning

confidence: 99%

Community-based care models for arterial hypertension management in non-pregnant adults in sub-Saharan Africa: a literature scoping review and framework for designing chronic services

et al. 2022

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Background Arterial hypertension (aHT) is the leading cardiovascular disease (CVD) risk factor in sub-Saharan Africa; it remains, however, underdiagnosed, and undertreated. Community-based care services could potentially expand access to aHT diagnosis and treatment in underserved communities. In this scoping review, we catalogued, described, and appraised community-based care models for aHT in sub-Saharan Africa, considering their acceptability, engagement in care and clinical outcomes. Additionally, we developed a framework to design and describe service delivery models for long-term aHT care. Methods We searched relevant references in Embase Elsevier, MEDLINE Ovid, CINAHL EBSCOhost and Scopus. Included studies described models where substantial care occurred outside a formal health facility and reported on acceptability, blood pressure (BP) control, engagement in care, or end-organ damage. We summarized the interventions’ characteristics, effectiveness, and evaluated the quality of included studies. Considering the common integrating elements of aHT care services, we conceptualized a general framework to guide the design of service models for aHT. Results We identified 18,695 records, screened 4,954 and included twelve studies. Four types of aHT care models were identified: services provided at community pharmacies, out-of-facility, household services, and aHT treatment groups. Two studies reported on acceptability, eleven on BP control, ten on engagement in care and one on end-organ damage. Most studies reported significant reductions in BP values and improved access to comprehensive CVDs services through task-sharing. Major reported shortcomings included high attrition rates and their nature as parallel, non-integrated models of care. The overall quality of the studies was low, with high risk of bias, and most of the studies did not include comparisons with routine facility-based care. Conclusions The overall quality of available evidence on community-based aHT care is low. Published models of care are very heterogeneous and available evidence is insufficient to recommend or refute further scale up in sub-Sahara Africa. We propose that future projects and studies implementing and assessing community-based models for aHT care are designed and described according to six building blocks: providers, target groups, components, location, time of service delivery, and their use of information systems.

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“…We collapsed the many DSD models recorded in SmartCare into eight groups based on the location and duration of medication dispensing: ≤2‐month fast‐track, 3‐month fast‐track, 4‐ to 6‐month fast‐track, 3‐month MMD, 4‐ to 6‐month MMD, CAGs, home ART delivery and all others. A description of each model can be found in Table 1 [ 11 ].…”

Section: Methodsmentioning

confidence: 99%

Changes in HIV treatment differentiated care uptake during the COVID‐19 pandemic in Zambia: interrupted time series analysis

Rosen

et al. 2021

J Int AIDS Soc.

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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.

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Differentiated Service Delivery Models for HIV Treatment in Malawi, South Africa, and Zambia: A Landscape Analysis

Cited by 32 publications

References 13 publications

Evaluation of HIV treatment outcomes with reduced frequency of clinical encounters and antiretroviral treatment refills: A systematic review and meta-analysis

Evaluation of HIV treatment outcomes with reduced frequency of clinical encounters and antiretroviral treatment refills: A systematic review and meta-analysis

Community-based care models for arterial hypertension management in non-pregnant adults in sub-Saharan Africa: a literature scoping review and framework for designing chronic services

Changes in HIV treatment differentiated care uptake during the COVID‐19 pandemic in Zambia: interrupted time series analysis

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