“Patients are not the same, so we cannot treat them the same” – A qualitative content analysis of provider, patient and implementer perspectives on differentiated service delivery models for HIV treatment in South Africa

Abstract

IntroductionIn 2014, the South African government adopted a differentiated service delivery (DSD) model in its “National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs)” (AGL) to strengthen the HIV care cascade. We describe the barriers and facilitators of the AGL implementation as experienced by various stakeholders in eight intervention and control sites across four districts.MethodsEmbedded within a cluster‐randomized evaluation of the AGL, we conducted 48 in‐depth interviews (IDIs) with healthcare providers, 16 IDIs with Department of Health and implementing partners and 24 focus group discussions (FGDs) with three HIV patient groups: new, stable and those not stable on treatment or not adhering to care. IDIs were conducted from August 2016 to August 2017; FGDs were conducted in January to February 2017. Content analysis was guided by the Consolidated Framework for Implementation Research. Findings were triangulated among respondent types to elicit barriers and facilitators to implementation.ResultsNew HIV patients found counselling helpful but intervention respondents reported sub‐optimal counselling and privacy concerns as barriers to initiation. Providers felt insufficiently trained for this intervention and were confused by the simultaneous rollout of the Universal Test and Treat strategy. For stable patients, repeat prescription collection strategies (RPCS) were generally well received. Patients and providers concurred that RPCS reduced congestion and waiting times at clinics. There was confusion though, among providers and implementers, around implementation of RPCS interventions. For patients not stable on treatment, enhanced counselling and tracing patients lost‐to‐follow‐up were perceived as beneficial to adherence behaviours but faced logistical challenges. All providers faced difficulties accessing data and identifying patients in need of tracing. Congestion at clinics and staff attitude were perceived as barriers preventing patients returning to care.ConclusionsImplementation of DSD models at scale is complex but this evaluation identified several positive aspects of AGL implementation. The positive perception of RPCS interventions and challenges managing patients not stable on treatment aligned with results from the larger evaluation. While some implementation challenges may resolve with experience, ensuring providers and implementers have the necessary training, tools and resources to operationalize AGL effectively is critical to the overall success of South Africa’s HIV control strategy.

Uptake of community‐ versus clinic‐based antiretroviral therapy dispensing in the Central Chronic Medication Dispensing and Distribution program in South Africa

“…Adherence clubs, or healthcare worker‐managed groups of PLWH that meet for ART pick‐up, as well as community‐based mobile DSD programs have demonstrated high rates of retention and virologic suppression [ 9 , 10 , 11 , 12 , 13 , 14 ]. Stakeholders have additionally reported cost savings and reduced clinic waiting times with community‐based DSD programs [ 15 , 16 ]. However, there are limited data from South Africa about patient uptake of fixed medication pick‐up points (PUPs).…”

Profiles of HIV Care Disruptions Among Adult Patients Lost to Follow-up in Zambia: A Latent Class Analysis

“… 4 These strategies are likely to be effective in only a subset of the patient population, and there is thus increasing recognition that the next phase of the global response to the HIV epidemic will require more targeted approaches. 4 , 6 , 15 Focusing on patient profiles that speak more to the underlying drivers of patient behaviors will be crucial when developing and implementing the next-generation of intervention strategies. First, these profiles highlight that more holistic strategies that seek to target the multiple barriers an individual may face, rather than individual ones, may be more effective at improving retention.…”

“…16 Second, they establish that several distinct intervention strategies will need to be implemented in order to address the care needs of the entire population. 6 For example, patients with competing work obligations may require increased flexibility and decreased burden for receiving care (ie, extending visit intervals). For others, travel and mobility are unavoidable and facilitating transfers (which are often associated with prolonged gaps in care 17 ) so they are seamless is needed.…”

“… 4 Lastly, they suggest the need for different interventions may vary across patient characteristics or the stage at which a patient is in their care (eg, newer versus more established patients). 6 These are actionable insights that remain durable for public health planning and should be integrated with data on patient preferences 19 , 20 . Additional research should now seek to elucidate what the most effective intervention strategies will be for different patient profiles—either through standard or more adaptive methods—as well as how to effectively target these different strategies.…”

“…2 , 3 There is also increasing recognition that these strategies—as opposed to being uniform and directed toward the entire patient population—will also need to be more targeted to account for the significant diversity in the patient population. 4 – 6 It is thus imperative that we develop a more comprehensive understanding of the heterogeneity in the HIV patient population to develop such targeted strategies to optimize the impact of the global HIV treatment response.…”