Retention in care and viral suppression in differentiated service delivery models for HIV treatment delivery in sub‐Saharan Africa: a rapid systematic review

Abstract

Introduction: Differentiated service delivery (DSD) models for antiretroviral treatment (ART) for HIV are being scaled up in the expectation that they will better meet the needs of patients, improve the quality and efficiency of treatment delivery and reduce costs while maintaining at least equivalent clinical outcomes. We reviewed the recent literature on DSD models to describe what is known about clinical outcomes. Methods: We conducted a rapid systematic review of peer-reviewed publications in PubMed, Embase and the Web of Science and major international conference abstracts that reported outcomes of DSD models for the provision of ART in sub-Saharan Africa from January 1, 2016 to September 12, 2019. Sources reporting standard clinical HIV treatment metrics, primarily retention in care and viral load suppression, were reviewed and categorized by DSD model and source quality assessed. Results and discussion: Twenty-nine papers and abstracts describing 37 DSD models and reporting 52 discrete outcomes met search inclusion criteria. Of the 37 models, 7 (19%) were facility-based individual models, 12 (32%) out-of-facility-based individual models, 5 (14%) client-led groups and 13 (35%) healthcare worker-led groups. Retention was reported for 29 (78%) of the models and viral suppression for 22 (59%). Where a comparison with conventional care was provided, retention in most DSD models was within 5% of that for conventional care; where no comparison was provided, retention generally exceeded 80% (range 47% to 100%). For viral suppression, all those with a comparison to conventional care reported a small increase in suppression in the DSD model; reported suppression exceeded 90% (range 77% to 98%) in 11/21 models. Analysis was limited by the extensive heterogeneity of study designs, outcomes, models and populations. Most sources did not provide comparisons with conventional care, and metrics for assessing outcomes varied widely and were in many cases poorly defined. Conclusions: Existing evidence on the clinical outcomes of DSD models for HIV treatment in sub-Saharan Africa is limited in both quantity and quality but suggests that retention in care and viral suppression are roughly equivalent to those in conventional models of care.

Twenty‐four‐month outcomes from a cluster‐randomized controlled trial of extending antiretroviral therapy refills in ART adherence clubs

“…Retention at 24 months was similar to community adherence clubs in Kwa‐Zulu Natal reporting 94.9% 12 to 24 month retention [41,42]. Twelve‐month retention (>97%) was similar to previous Western Cape AC studies that reported 95% to 97% [8,35,43,44], and higher than 89.5% reported from a South African AC model evaluation comparing 24 randomly allocated intervention and control facilities undertaken in Gauteng, Kwa‐Zulu Natal, Limpopo and North West provinces at the same time point [9].…”

Expanding the Vision for Differentiated Service Delivery: A Call for More Inclusive and Truly Patient-Centered Care for People Living With HIV

“…Preliminary data evaluating the outcomes of DSD treatment programs across multiple countries 10 support the concept that continued scale-up of DSD is critical to attaining the ambitious coverage, retention, and quality targets of the global HIV response. 11 However, simplifying ART delivery for clinically stable PLHIV is not sufficient to meet all of their health care needs, which often include prevention and treatment of tuberculosis (TB), routine preventive and primary care, family planning (FP), and noncommunicable disease (NCD) services.…”

Client and provider preferences for HIV care: Implications for implementing differentiated service delivery in Thailand

“…community adherence groups), healthcare worker-managed groups (i.e. adherence clubs), facility-based individual models, which include appointment spacing and fast-track drug refill, and out-of-facility individual models, which include community drug distribution points and home delivery [10,11], with generally high retention and viral suppression of over 80% and 90% respectively [12]. A couple of examples were identified in Asia: telemedicine with e-consultation and ART delivery via courier service has been available for stable clients at SHIP Clinic in the Philippines [13], and gay-led, fee-based ART maintenance service at G-link Clinic in Vietnam has provided online counselling in addition to its facility-based service [14].…”