Can differentiated care models solve the crisis in HIV treatment financing? Analysis of prospects for 38 countries in sub-Saharan Africa

Perceptions and attitudes towards unmanned aerial vehicles (drones) use for delivery of HIV medication among fisher folk communities on the Islands of Kalangala, Uganda

The study aimed to assess the attitudes of stakeholders towards the use of unmanned aerial vehicles (medical drones) for delivering antiretroviral therapy (ART) in the Kalangala district of Uganda, which is comprised of 84 islands and has approximately 18,500 People Living with HIV (PLHIV). A qualitative baseline study was conducted to assess the acceptability and feasibility of using a medical drone for ART delivery in the island settlements of Kalangala Islands. The data revealed four emerging themes: knowledge about the drones, perceived benefits of medical drone delivery, perceived risks of medical drone use, and recommendations for future use. The study found that most participants, especially healthcare workers and key opinion leaders, were aware of the medical drones, which could reduce transport costs, deliver medication on time, and reduce healthcare workers' workload. However, there were also perceived risks related to the use of medical drones, such as stigma, reduced contact with healthcare providers, and maintenance and security issues. The study provided evidence that medical drones would be acceptable and have support from various stakeholders in the island settlements for ART delivery. However, concerns were raised about potential stigma and less health worker interaction. This qualitative work allowed the team to address these concerns during the pilot phase.

Uptake of community-based differentiated antiretroviral therapy service delivery and associated factors among people living with HIV in Ethiopia: a multicenter cross-sectional study

Background

Achieving the 95-95-95 targets require an efficient and innovative person-centered approach, specifically community-based differentiated service delivery (DSD), to improve access to human immunodeficiency virus (HIV) services and reduce burdens on the health system. Therefore, this study aimed to assess the uptake of community-based DSD models and associated factors among people living with HIV (PLHIV).

Methods

A multicenter cross-sectional study was conducted among PLHIV in public health facilities in South Ethiopia. Data were collected and entered into EpiData version 3.1 before being exported to Stata version 14 for further analysis. In the bivariable logistic regression analysis, variables with a p-value of ≤0.25 were included in the multivariable logistic regression analysis. A p-value of <0.05 was used to identify statistically significant factors.

Results

Among 381 stable PLHIV, 55.91% were women. The median age (interquartile range) was 40 years (27-53). The uptake of community-based DSD models was 19.16%. Residence and disclosure were the two independent factors significantly associated with the uptake of community-based DSD models.

Conclusion

One out of five stable PLHIV on antiretroviral therapy uptake the community-based DSD models. Improvement in uptake is needed in Ethiopia's resource-limited healthcare system to better achieve the 95-95-95 targets.

Cost-effectiveness of differentiated care models that incorporate economic strengthening for HIV antiretroviral therapy adherence: a systematic review

BACKGROUND

There is some evidence that differentiated service delivery (DSD) models, which use a client-centered approach to simplify and increase access to care, improve clinical outcomes among people living with HIV (PLHIV) in high HIV prevalence countries. Integrating economic strengthening tools (e.g., microcredit, cash transfers, food assistance) within DSD models can help address the poverty-related barriers to HIV antiretroviral therapy (ART). Yet there is minimal evidence of the cost-effectiveness of these types of multilevel care delivery models, which potentially prohibits their wider implementation.

METHODS

Using a qualitative systematic review, this article synthesizes the literature surrounding the cost-effectiveness of differentiated service delivery models that employ economic strengthening initiatives to improve HIV treatment adherence in low- and middle-income countries. We searched three academic databases for randomized controlled trials and observational studies published from January 2000 through March 2024 in Sub-Saharan Africa. The quality of each study was scored using a validated appraisal system.

RESULTS

Eighty-nine full texts were reviewed and 3 met all eligibility criteria. Two of the three included articles were specific to adolescents living with HIV. Economic strengthening opportunities varied by care model, and included developmental savings accounts, microenterprise workshops, and cash and non-cash conditional incentives. The main drivers of programmatic and per-patient costs were ART medications, CD4 cell count testing, and economic strengthening activities.

CONCLUSION

All economic evaluations in this review found that including economic strengthening as part of comprehensive differentiated service delivery was cost-effective at a willingness to pay threshold of at least 2 times the national per capita gross domestic product. Two of the three studies in this review focused on adolescents, suggesting that these types of care models may be especially cost-effective for youth entering adulthood. All studies were from the provider perspective, indicating that additional evidence is needed to inform the potential cost-savings of DSD and economic strengthening interventions to patients and society. Randomized trials testing the effectiveness of DSD models that integrate economic strengthening should place greater emphasis on costing these types of programs to inform the potential for bringing these types of multilevel interventions to scale.

Cost-Effectiveness and Budget Impact Analysis of the Implementation of Differentiated Service Delivery Models for HIV Treatment in Mozambique: a Modelling Study

INTRODUCTION

In 2018, the Mozambique Ministry of Health launched guidelines for implementing differentiated service delivery models (DSDMs) to optimize HIV service delivery, improve retention in care, and ultimately reduce HIV-associated mortality. The models were fast-track, 3-month antiretrovirals dispensing, community antiretroviral therapy groups, adherence clubs, family approach and three one-stop shop models: adolescent-friendly health services, maternal and child health, and tuberculosis. We conducted a cost-effectiveness analysis and budget impact analysis to compare these models to conventional services.

METHODS

We constructed a decision tree model based on the percentage of enrolment in each model and the probability of the outcome (12-month retention in treatment) for each year of the study period-three for the cost-effectiveness analysis (2019-2021) and three for the budget impact analysis (2022-2024). Costs for these analyses were primarily estimated per client-year from the health system perspective. A secondary cost-effectiveness analysis was conducted from the societal perspective. Budget impact analysis costs included antiretrovirals, laboratory tests and service provision interactions. Cost-effectiveness analysis additionally included start-up, training and clients' opportunity costs. Effectiveness was estimated using an uncontrolled interrupted time series analysis comparing the outcome before and after the implementation of the differentiated models. A one-way sensitivity analysis was conducted to identify drivers of uncertainty.

RESULTS

After implementation of the DSDMs, there was a mean increase of 14.9 percentage points (95% CI: 12.2, 17.8) in 12-month retention, from 47.6% (95% CI, 44.9-50.2) to 62.5% (95% CI, 60.9-64.1). The mean cost difference comparing DSDMs and conventional care was US$ -6 million (173,391,277 vs. 179,461,668) and -32.5 million (394,705,618 vs. 433,232,289) from the health system and the societal perspective, respectively. Therefore, DSDMs dominated conventional care. Results were most sensitive to conventional care interaction costs in the one-way sensitivity analysis. For a population of 1.5 million, the base-case 3-year financial costs associated with the DSDMs was US$550 million, compared with US$564 million for conventional care.

CONCLUSIONS

DSDMs were less expensive and more effective in retaining clients 12 months after antiretroviral therapy initiation and were estimated to save approximately US$14 million for the health system from 2022 to 2024.

Stability in care and risk of loss to follow-up among clients receiving community health worker-led differentiated HIV care: Results from a prospective cohort study in northern Tanzania

BACKGROUND

HIV services in Tanzania are facility-based but facilities are often overcrowded. Differentiated care models (DCM) have been introduced into the National Guidelines. We piloted a Community Health Worker (CHW)-led HIV treatment club model (CHW-DCM) in an urban region, and assessed its effectiveness in comparison to the standard of care (SoC, facility-based model), in terms of stability in care, loss to follow-up (LTFU) and treatment adherence.

METHODS

In two clinics in the Shinyanga region, clients established on ART (defined as stable clients by national guidelines as on first-line ART >6 months, undetectable viral load, no opportunistic infections or pregnancy, and good adherence) were offered CHW-DCM. This prospective cohort study included all stable clients who enrolled in CHW-DCM between July 2018 and March 2020 (CHW-DCM) and compared them to stable clients who remained in SoC during that period. Multivariable Cox regression models were used to analyse factors associated with continued stability in care and the risk of LTFU during 18 months of follow-up; treatment adherence was assessed by pill count and compared using Chi-square tests.

RESULTS

Of 2472 stable clients, 24.5% received CHW-DCM and 75.5% SoC. CHW-DCM clients were slightly older (mean 42.8 vs. 37.9 years) and more likely to be female (36.2% vs. 32.2%). Treatment adherence was better among CHW-DCM than SoC: 96.6% versus 91.9% and 98.5% versus 92.2%, respectively (both p = 0.001). SoC clients were more likely to not remain stable over time than CHW-DCM (adjusted Hazard ratio [AHR] = 2.68; 95% CI: 1.86-3.90). There was no difference in LTFU (adjusted hazard ratio [AHR] = 1.54; 95%CI: 0.82-2.93).

CONCLUSION

Clients attending CHW-DCM demonstrated better stability in care and treatment adherence than SoC, and the risk of LTFU was not increased. These findings demonstrate the potential of CHW in delivering community-based HIV services in the local Tanzanian context. These results could be used to extend this CHW-DCM model to similar settings.

Effects of Multi-Month Dispensing on Clinical Outcomes: Retrospective Cohort Analysis Conducted in Kenya

Multi-month dispensing (MMD) has been widely adopted by national HIV programs as a key strategy for improving the quality of HIV care and treatment services while meeting the unique needs of diverse client populations. We assessed the clinical outcomes of clients receiving MMD in Kenya by conducting a retrospective cohort study using routine programmatic data in 32 government health facilities in Kenya. We included clients who were eligible for multi-month antiretroviral therapy (ART) dispensing for ≥ 3 months (≥ 3MMD) according to national guidelines. The primary exposure was enrollment into ≥ 3MMD. The outcomes were lost to follow-up (LTFU) and viral rebound. Multilevel modified-Poisson regression models with robust standard errors were used to compare clinical outcomes between clients enrolled in ≥ 3MMD and those receiving ART dispensing for less than 3 months (< 3MMD). A total of 3,501 clients eligible for ≥ 3MMD were included in the analysis, of whom 65% were enrolled in ≥ 3MMD at entry into the cohort. There was no difference in LTFU of ≥ 180 days between the two types of care (aRR 1.1, 95% CI 0.7-1.6), while ≥ 3MMD was protective for viral rebound (aRR 0.1 95% CI 0.0-0.2). As more diverse client-focused service delivery models are being implemented, robust evaluations are essential to guide the implementation, monitor progress, and assess acceptability and effectiveness to deliver optimal people-centered care.

Achieving HIV Epidemic Control and Improving Maternal Healthcare Services with Community-Based HIV Service Delivery in Zambia: Mixed-Methods Assessment of the SMACHT Project

Novel community-based approaches are needed to achieve and sustain HIV epidemic control in Zambia. Under the Stop Mother and Child HIV Transmission (SMACHT) project, the Community HIV Epidemic Control (CHEC) differentiated service delivery model used community health workers to support HIV testing, ART linkage, viral suppression, and prevention of mother-to-child transmission (MTCT). A multi-methods assessment included programmatic data analysis from April 2015 to September 2020, and qualitative interviews from February to March 2020. CHEC provided HIV testing services to 1,379,387 clients; 46,138 were newly identified as HIV-positive (3.3% yield), with 41,366 (90%) linked to ART. By 2020, 91% (60,694/66,841) of clients on ART were virally suppressed. Qualitatively, healthcare workers and clients benefitted from CHEC, with provision of confidential services, health facility decongestion, and increased HIV care uptake and retention. Community-based models can increase uptake of HIV testing and linkage to care, and help achieve epidemic control and elimination of MTCT.

Barriers and Facilitators to Utilization of Community Drug Distribution Points Among People Living with HIV in Bushenyi District, South-Western Uganda: A Qualitative Study

Introduction

People living with HIV (PLHIV) still have challenges in accessing HIV services in low- and middle-income countries (LMIC). In Uganda, community drug distribution points (CDDPs) are part of interventions to improve access to anti-retroviral medications. However, there is still low enrollment in CDDPs among PLHIV in south-western Uganda, particularly in Bushenyi district. This study explored the barriers and facilitators to the utilization of CDDPs among PLHIV.

Methods

This was a descriptive qualitative study utilizing a qualitative approach. We purposively recruited 24 PLHIV and 6 Primary healthcare providers as key informants. We conducted in-depth interviews with PLHIV and key informant interviews with Primary healthcare providers using an interview guide. The audio recordings were transcribed verbatim to Rukiga-Runyankore and then translated into English. Data were coded and analyzed using thematic analysis.

Results

Seven themes were developed describing drivers for the utilization of CDDPs. These were broadly categorized into facilitators and barriers. The main facilitators of the utilization of CDDPs were peer support, positive Primary healthcare providers' attitudes, satisfaction with HIV services, and accessibility of ART services. The main barriers were stigma, lack of physical infrastructure, and lack of comprehensive services.

Conclusion and Recommendation

Utilization of CDDPs is facilitated by accessibility and Primary healthcare providers' attitude. Stigma is still a limitation to the utilization of HIV services. We recommend that Ministry of Health and other development partners should improve physical infrastructural facilities at the CDDP sites so that the privacy and confidentiality of the PLHIV are protected. Focus on interventions to eliminate stigma by Primary healthcare providers and other stakeholders at CDDP sites is urgently needed.

Factors Influencing ART Adherence Among Persons Living with HIV Enrolled in Community Client-Led Art Delivery Groups in Lira District, Uganda: A Qualitative Study

Background

Community client-led ART delivery groups (CCLADs) were introduced as one of the strategies to better serve individual needs and reduce unnecessary burdens on the health system. However, limited data adequately explained the factors influencing ART adherence among HIV/AIDS patients in CCLAD's model of care. The study aimed to assess the factors influencing ART adherence among HIV-positive patients attending CCLADs in Lira District, Uganda.

Materials and Methods

We employed a qualitative method of data collection recruiting 25 study participants (expert clients) between July and August 2020. The study purposefully chose 25 participants to participate in with HIV/AIDS patients enrolled in community-based HIV care models. The interviews were recorded on audiotape, transcribed, and translated verbatim. We used a thematic approach to analyze the data.

Results

Our study shows that social support among group members, patient self-motivation, counselling, and guidance were the major facilitators of adherence. From the analysis of results, our study found the following themes: Lack of food, stigma, forgetfulness, stress, unfair staff at the hospital, and socio-cultural beliefs were among the major barriers identified in this study.

Conclusion

The study emphasizes that CCLADs improve ART adherence for HIV-positive clients by providing a supportive environment and medication access. Peer influence on alternative medicine usage hinders adherence. We recommend that continued support, funding, and education are necessary to address misconceptions and sustain CCLADs' effectiveness.

HIV Treatment and Care of Adolescents: Perspectives of Adolescents on Community-Based Models in Northern Uganda

Background

Differentiated service delivery models for people living with HIV continue to be scaled up to expand access to HIV services and treatment continuity. However, there is a gap in information on adolescents' perspectives on community-based models. We aimed to explore the perspectives of adolescents living with HIV on community-based models in northern Uganda.

Materials and Methods

Between February and March 2022, we conducted a descriptive qualitative study at two health centres IV in Northern Uganda. Data was collected using an interview guide. The study had 25 purposively selected adolescents enrolled in community-based models for HIV care and treatment. The interviews were audio-recorded, transcribed verbatim, and translated. We analyzed data using a thematic approach.

Results

A total of 25 in-depth interviews with HIV-positive adolescents were conducted. More than half (52.0%) of the participants were females, 84.0% were not married, and 44.0% had no formal education. The mean age of the respondents was 15.6 (±1.9) years. The major themes were: community-based models currently accessed by adolescents, benefits, and challenges of the models. Although there are other community-based models (community pharmacies, home ART deliveries) our exploration only discovered two models used by these adolescents to access care, namely, Community Drug Distribution Point (CDDP) and Community Client-Led ART Delivery Groups (CCLADs). The benefits included reduced transportation costs, convenient service access, ART adherence, peer support, a comfortable environment and less stress. However, our results indicate that these models had some challenges, including lack of confidentiality and privacy, perceived stigma, and a lack of face-to-face interaction.

Conclusion

Our findings show that CDDP and CCLADs are the two CBMs used by adolescents in Lira District to access treatment and care. Adolescents benefited from these models through reduced transport costs, the convenience of accessing HIV care and treatment, and social support. The challenges associated with these models are lack of confidentiality and privacy, perceived stigma, and a lack of face-to-face interaction. The Ministry of Health should work with other implementing partners to strengthen the implementation of these models to improve HIV/AIDS service delivery for adolescents.

Uptake of community antiretroviral group delivery models for persons living with HIV in Arua district, Uganda: A parallel convergent mixed methods study

Community antiretroviral groups (CAGs) is one of the innovative and efficient differentiated service delivery models (DSDM) for reaching persons needing human immunodeficiency virus (HIV) treatment in the community. Since DSDM adoption in Uganda, evidence suggests better care outcomes for patients in DSDM compared to counterparts in routine health facility care. However, uptake of CAG models for eligible community groups of persons living with HIV (PLHIV) has been slow in Arua district, Uganda and stakeholders' perceptions regarding its implementation unexplored. The objective of the study was to determine the uptake, barriers and facilitators influencing CAG model implementation in Arua district, Uganda. We conducted a parallel convergent mixed-methods study from March 2020 to December 2020 at Adumi health centre IV and Kuluva hospital in Arua district. We enrolled and extracted data for every fifth virally suppressed participant on antiretroviral therapy (ART) at the two health facilities. Data were analysed using STATA 13.0. Uptake was determined as the proportion of eligible PLHIV that were enrolled into a group. We performed logistic regression to determine factors associated with uptake. We conducted one focus group discussion per facility among healthcare workers involved in the management of PLHIV. We also conducted 7 focus group discussions among PLHIV across the two facilities. Thematic analysis was used to describe the data. A total of 399 PLHIV were eligible for CAG, 61.6% were female, and 44.9% were on dolutegravir (DTG) based regimen. Uptake was 6.8%, 95% CI (4.7-9.7) and was found to be significantly associated with being divorced or separated in a marriage (OR; 0.14, 95%CI; 0.02-0.92, P = 0.014). Members picking drugs in turns, comforting and encouraging others to take the drugs, and health workers advising them to join and stay with other group members were perceived as facilitators to uptake of community antiretroviral group delivery model. Having few and distant eligible members in the local area to form a group, lack of transport among the member to pick the drugs when it's their turn, misunderstandings and lack of confidentiality amongst the members, and lack of partner disclosure were perceived as barriers to uptake of community antiretroviral group delivery model. Uptake of community antiretroviral group delivery model in Arua district is very low. There may be a need to support community antiretroviral group delivery models with income- generating activities, transport facilitation, closer community drug pick-up points and improved partner disclosure support mechanisms among married group members.

'I need time to start antiretroviral therapy': understanding reasons for delayed ART initiation among people diagnosed with HIV in Lusaka, Zambia'

INTRODUCTION

Rapid antiretroviral therapy (ART) initiation can improve patient outcomes such as viral suppression and prevent new infections. However, not everyone who can start ART does so immediately.

METHODS

We conducted a qualitative study to inform interventions supporting rapid initiation in the 'Test and Start' era. We purposively sampled 20 adult patients living with HIV and a previous gap in care from ten health facilities in Lusaka, Zambia for interviews. We inductively analysed transcripts using a thematic, narrative approach. In their narratives, seven participants discussed delaying ART initiation.

RESULTS

Drawing on messages gleaned from facility-based counselling and community information, many cited greater fear of rapid sickness or death due to imperfect adherence or treatment side effects than negative health consequences due to delayed initiation. Participants described needing time to 'prepare' their minds for a lifetime treatment commitment. Concerns about inadvertent HIV status disclosure during drug collection discouraged immediate initiation, as did feeling healthy, and worries about the impact of ART initiation on relationship dynamics.

CONCLUSION

Findings suggest that counselling messages should accurately communicate treatment risks, without perpetuating fear-based narratives about HIV. Identifying and managing patient-specific concerns and reasons for the 'need for time' may be important for supporting individuals to rapidly accept lifelong treatment.Key messagesFear-based adherence messaging in health facilities about the dangers of missing a treatment dose or changing the time when ART is taken contributes to Zambian patients' refusals of immediate ART initiationResponsive health systems that balance a stated need for time to accept one's diagnosis and prepare to embark on a lifelong treatment plan with interventions to identify and manage patient-specific treatment related fears and concerns may support more rapid ART initiationPerceived social stigma around HIV continues to be a significant challenge for treatment initiation.

Benefits and challenges of community-based multi-month dispensing of antiretroviral treatment in Zimbabwe: A qualitative study from a cluster randomized trial

Sub-Saharan Africa carries the highest burden of HIV, with approximately 70% of all people living with HIV (PLWH) globally living in this region. The provision of antiretroviral treatment (ART) significantly affects already overburdened health systems, which need to accommodate large volumes of ART patients while facing a shortage of professional health workers, infrastructure challenges and medical resources. Finding alternative ways to provide routine services to PLWH has become significantly more urgent. Multi-month dispensing (MMD) of ART aims to improve access to treatment for PLWH, while also improving the efficiency of the health system. This study explores the experienced benefits and challenges of community-based MMD in order to make recommendations for future implementation efforts. Twenty focus group discussions were conducted with members of community ART refill groups (CARGs) who received 3-monthly or 6-monthy MMD. Individual interviews were also conducted with health providers. All interviews and focus group discussions took place between April and June 2019 conducted by research nurses in English, Shona or Ndebele. Multiple benefits of community-based MMD were reported, including decreased congestion in health facilities, improved service delivery, decline in staff burnout and increased time availability for CARG members due to less time spent at clinics, improved ART adherence and social support experienced amongst members of CARGs. Identified challenges included the possibility of being exposed to HIV-related stigma when belonging to a CARG, and low levels of medical supplies and ART stock at clinics. Recommendations were made by CARG members and health care workers on how CARGs could be improved and sustained in the future. Results from this study show that the implementation of community-based MMD holds multiple benefits at an individual and health facility level. Future recommendations include evaluating the feasibility of MMD among other vulnerable populations.

Implementation of Electronic Adherence Monitors and Associated Interventions for Routine HIV Antiretroviral Therapy in Uganda: Promising Findings

Background

High, sustained adherence is critical for achieving the individual and public health benefits of HIV antiretroviral therapy (ART). Electronic monitors provide detailed adherence information and can enable real-time interventions; however, their use to date has largely been confined to research. This pilot study (NCT03825952) sought to understand feasibility and acceptability a relatively low-cost version of this technology and associated interventions for routine ART delivery in sub-Saharan Africa.

Methods

We provided two ART clinics in rural, southwestern Uganda with electronic adherence monitors for data-informed counseling as well as optional SMS messages to clients and/or social supporters (daily or triggered by missed or delayed doses) and/or an alarm. Clinic and ART client experiences were observed for 3 months per client, including time and motion studies. Qualitative interviews among clients, clinicians, and healthcare administrators were informed by the Consolidated Framework for Implementation Research.

Results

Fifty-one ART clients were enrolled; 57% were male and the median age was 34 years. Choice of associated intervention varied among participants. The median number of visits during follow-up was two per client. Counselors reviewed the adherence data with 90% of clients at least once; 67% reviewed data at all visits. Average adherence was 94%; four clients had adherence gaps >1 week. Acceptability was high; all but one client found the monitor "very useful” and all found SMS “very useful.” Clinic visits among clients with the intervention lasted 4 min longer on average than those in standard care. The monitors and daily SMS generally functioned well, although excess SMS were triggered, primarily due to cellular network delays. Overall, participants felt the technology improved adherence, clinic experiences, and clinician-client relationships. Few worried about stigma and privacy. Cost was a concern for implementation, particularly at scale.

Conclusion

We successfully implemented a relatively low-cost electronic ART adherence monitor and associated interventions for routine care in rural Uganda. Feasibility and acceptability were generally high, and individuals were identified who could benefit from adherence support. Future work should involve longitudinal follow-up of diverse populations, clinical outcomes, and detailed cost-effectiveness analysis to help drive policy decisions around the uptake of this technology for routine clinical care.

Clinical Trial Registration

identifier: NCT03825952.

An empiric tool to identify Kenyans living with HIV who will have unsuppressed viremia 18 months following treatment initiation to guide differentiated care models

Background

With the global push towards universal access to Antiretroviral Treatment (ART), patient numbers are increasing, further straining already under-resourced healthcare systems in sub-Saharan Africa. A simple scoring tool could be useful in optimizing differentiated service delivery by identifying individuals likely to have unsuppressed viral load.

Methods

Using existing data of patients accessing ART at public health facilities that were extracted from the Kenya Electronic Medical Record (KenyaEMR) and standard methods of developing a clinical prediction tool; we created and validated a risk scoring tool to identify persons likely to be virally unsuppressed at 18 months post-ART initiation. Data from the KenyaEMR were cleaned, merged and reviewed for completeness. We utilized multivariate modelling to determine key predictors of viral load suppression that could be measured in clinical settings.

Results

We assessed clinical reports of 3,968 patients on ART who had been on ART for at least 18 months and had at least one viral load result and were ≥ 18 years old. Of these, the majority (81%) were virally suppressed 18 months post-ART initiation. The final risk score included age, sex, body mass index at HIV diagnosis, number of years of formal education, disclosure status, and duration of time between HIV diagnosis and initiating ART. The maximum risk score was 78; a risk score of ≥22 was associated with unsuppressed viral load (>1000copies/mL). The area under the curve (AUC) for the probability of the risk score to correctly predict unsuppressed viral load was 0.55 (95% CI: 0.52 to 0.56). Internal and external validation showed similar predictive ability.

Conclusions

Routinely collected variables in a public HIV clinic medical record predicts, with modest accuracy, individuals likely to have unsuppressed HIV viremia 18 months after they initiate ART. The use and application of this tool could improve and complement efficiency in differentiated care models for patients on ART.

Hearing From Men Living With HIV: Experiences With HIV Testing, Treatment, and Viral Load Suppression in Four High-Prevalence Countries in Sub-Saharan Africa

Engaging men in HIV services remains a challenge across sub-Saharan Africa. There is a critical need to better understand facilitators of men's successful engagement with HIV services and assess if there are similarities across contexts. We conducted in-depth interviews and focus group discussions with 92 men living with HIV (MLHIV) across Malawi, Uganda, South Africa, and Eswatini, most of whom had been diagnosed with HIV within the last 5 years. We coded interviews for themes using a constant-comparative approach. We contextualized our findings within a socioecological framework. HIV testing was primarily motivated by illness (individual level), though illness was sometimes accompanied by prompting and support from healthcare providers and/or intimate partners. Once diagnosed, nearly all participants reported immediate linkage to care, initiation of antiretroviral therapy (ART), and subsequent ART adherence. ART initiation and adherence were facilitated by men's sense of agency and ownership over their health (individual level), social support from intimate partners, friends, and family (interpersonal/network level), supportive-directive counseling from healthcare providers (institutional/health systems level), and male-friendly services, i.e., rapid, respectful, private (institutional/health systems level). Health literacy regarding viral suppression (individual level), strengthened by patient-provider communication (institutional/health systems level), was highest in Uganda, where most men could discuss viral load testing experiences, report their viral load status (most reported suppressed), and demonstrate an understanding of treatment as prevention. Elsewhere, few participants understood what viral load suppression was and even fewer knew their viral load status. Our findings reveal socioecological-level facilitators of men's progress across the HIV-care continuum. Programs may want to leverage facilitators of ART initiation and adherence that span socioecological levels—e.g., healthcare ownership and agency, social support, supportive-directive counseling—and apply them to each end of the continuum to encourage early HIV testing/diagnosis and improve health literacy to help men understand and achieve viral load suppression.

Do differentiated service delivery models for HIV treatment in sub-Saharan Africa save money? Synthesis of evidence from field studies conducted in sub-Saharan Africa in 2017-2019

Introduction: "Differentiated service delivery" (DSD) for antiretroviral therapy (ART) for HIV is rapidly being scaled up throughout sub-Saharan Africa, but only recently have data become available on the costs of DSD models to healthcare providers and to patients. We synthesized recent studies of DSD model costs in five African countries. Methods: The studies included cluster randomized trials in Lesotho, Malawi, Zambia, and Zimbabwe and observational studies in Uganda and Zambia. For 3-5 models per country, studies collected patient-level data on clinical outcomes and provider costs for 12 months. We compared costs of differentiated models to those of conventional care, identified drivers of cost differences, and summarized patient costs of seeking care. Results: The studies described 22 models, including conventional care. Of these, 13 were facility-based and 9 community-based models; 15 were individual and 7 group models. Average provider cost/patient/year ranged from $100 for conventional care in Zambia to $187 for conventional care with 3-month dispensing in Zimbabwe. Most DSD models had comparable costs to conventional care, with a difference in mean annual cost per patient ranging from 11.4% less to 9.2% more, though some models in Zambia cost substantially more. Compared to all other models, models incorporating 6-month dispensing were consistently slightly less expensive to the provider per patient treated. Savings to patients were substantial for most models, with patients' costs roughly halved. Conclusion: In five field studies of the costs of DSD models for HIV treatment, most models within each country had relatively similar costs to one another and to conventional care. 6-month dispensing models were slightly less expensive, and most models provided substantial savings to patients. Limitations of our analysis included differences in costs included in each study. Research is needed to understand the effect of DSD models on the costs of ART programmes as a whole.

"My condition is my secret": perspectives of HIV positive female sex workers on differentiated service delivery models in Kampala Uganda

BACKGROUND

Differentiated service delivery (DSD) models for female sex workers (FSWs) continue to be scaled up with the goal of expanding access to HIV services and treatment continuity. However, little is known about FSWs' perspectives on their preferences, facilitators, and barriers to the effective utilization of various DSD models.

METHODS

We conducted 24 in-depth interviews among FSWs on antiretroviral therapy for at least one year in two drop-in centres and two public health facilities in Kampala, Uganda in January 2021.

RESULTS

The facility-based individual management model was most preferred, due to a wide array of comprehensive health services, privacy, and professional health workers. Community DSD models were physically accessible, but least preferred due to stigmatization and discrimination, lack of privacy and confidentiality, and limited health services offered.

CONCLUSION

Targeted strategies to reduce stigma and discrimination and the provision of high-quality services have potential to optimise FSWs' access to HIV services.

Perspectives on preparing for long-acting injectable treatment for HIV among consumer, clinical and nonclinical stakeholders: A qualitative study exploring the anticipated challenges and opportunities for implementation in Los Angeles County

Long-acting injectable (LAI) antiretroviral therapy (ART) is a novel HIV treatment option for people with HIV. The first LAI ART regimen for HIV treatment received regulatory approval in the United States in January 2021. In February 2020, we collected qualitative data from 18 consumers and 23 clinical and non-clinical stakeholders to catalog anticipated individual-consumer, healthcare system, and structural levels barriers and facilitators to LAI ART implementation in Los Angeles County, California. Thematic analysis was guided by the CFIR implementation science model. CFIR constructs of intervention characteristics, individual characteristics, outer and inner setting, intervention characteristics, and implementation process emerged in analysis. Under intervention characteristics, anticipated facilitators included the relative advantage of LAI ART over pills for adherence and reduced treatment management burden and related anxiety; anticipated barriers included non-adherence to injection appointments, concerns of developing HIV resistance, discomfort with injection and cost. Anticipated facilitators based on individual characteristics included overall acceptability based on knowledge and positive beliefs about LAI ART. Participant noted several characteristics of the outer setting that could negatively impact implementation, such as medical mistrust, external policies, and LAI ART eligibility (i.e., to be virally suppressed prior to initiation). Participants were optimistic about the potential to decrease stigma but expressed that provider willingness for adoption could be hindered by challenges in organizational inner setting related to payment authorizations, increased staffing needs, medication procurement and storage, and provider and healthcare system readiness. Results from this pre-implementation study may inform rollout and scale-up of LAI ART in Los Angeles County.

Do differentiated service delivery models for HIV treatment in sub-Saharan Africa save money? Synthesis of evidence from field studies conducted in sub-Saharan Africa in 2017-2019

Introduction: "Differentiated service delivery" (DSD) for antiretroviral therapy (ART) for HIV is rapidly being scaled up throughout sub-Saharan Africa, but only recently have data become available on the costs of DSD models to providers and patients. We synthesized recent studies of DSD model costs in five African countries. Methods: The studies included cluster randomized trials in Lesotho, Malawi, Zambia, and Zimbabwe and observational studies in Uganda and Zambia. For 3-5 models per country, studies collected patient-level data on clinical outcomes and provider costs for 12 months, and some studies surveyed patients about costs they incurred. We compared costs of differentiated models to those of conventional care and identified drivers of cost differences. We also report patient costs of seeking care. Results: The studies described 22 models, including facility-based conventional care. Of these, 13 were facility-based and 9 community-based models; 15 were individual and 7 group models. Average provider cost/patient/year ranged from $100 in Zambia to $187 in Zimbabwe, in both cases for facility-based conventional care. Conventional care was less expensive than any other model in the Zambia observational study, more expensive than any other model in Lesotho, Malawi, and Zimbabwe, and in the middle of the range in the Zambia trial and the observational study in Uganda. Models incorporating 6-month dispensing were consistently less expensive to the provider per patient treated. Savings to patients were substantial for most models, with patients' costs roughly halved. Conclusion: In five field studies of the costs of DSD models for HIV treatment, most models within each country had relatively similar costs, except for 6-month dispensing models, which were slightly less expensive. Most models provided substantial savings to patients. Research is needed to understand the effect of DSD models on the costs of ART programmes as a whole.

Higher Clinician-Patient Communication Is Associated With Greater Satisfaction With HIV Care

Provider-patient communication (PPC) skills are key in promoting patient satisfaction. Our study examined the relationship between clinician PPC skills and patient satisfaction with care among virally unsuppressed adult HIV patients in Busia County, Kenya. This cross-sectional study was conducted among 360 HIV patients on first line antiretroviral regimen and having a recent viral load ≥400 copies HIV RNA/ml. We conducted logistic regression analysis. The mean age of participants was 48.2 years [standard deviation (SD): 12.05]. Overall, the mean score on clinician PPC skills was 33.3 (SD: 9.0). A high proportion (85%) of participants reported satisfaction with the HIV care services. After adjusting for covariates, the odds of being satisfied with care increased by 19% (adjusted odds ratio: 1.19, 95% CI: 1.11-1.30) for every one unit increase in the clinician PPC skills score. Promoting good PPC skills may be key to improving patient satisfaction with HIV care.

Service Use and Resilience among Adolescents Living with HIV in Blantyre, Malawi

Introduction:

Adolescents living with HIV (ALHIV) experience social and health challenges that warrant the provision of services and relational support to build resilience. Little is known about how social, community and health services help. We examine formal and alternative service use by and resilience of ALHIV participating in an enhanced teen-club clinic (TCC) programme.

Description:

TCC is an adolescent-centred differentiated care model offering a ‘one-stop-shop’ for HIV/Sexual and Reproductive Health (SRH) services to ALHIV. A survey was conducted with 406 ALHIV to determine frequency of use and satisfaction with services. In addition, we conducted 26 in-depth interviews with ALHIV, 12 group discussions with 144 caregivers, and observations of workshops held for 35 health workers to capture multiple perspectives on service use and relational support systems for adolescent’s wellbeing.

Discussion:

About 70% of ALHIV were concurrently clients of three or more services. The multi-method analysis showed variations on risks, range of services, frequency of use and satisfaction. Interview data reflected complex factors influencing access to formal services, and caregivers and adolescents also sought alternative care from spiritual and traditional healers.

Conclusion:

Adolescent centred-approaches have the potential to enhance resilience promoting resources and outcomes. A multi-sectoral approach to service use and provision is critical to inform adolescent intervention programs and wellbeing.

Differentiated service delivery models among PLHIV in Akwa Ibom and Cross River States, Nigeria during the COVID-19 pandemic: descriptive analysis of programmatic data

Introduction

The rapid increase in the number of people living with HIV (PLHIV) on antiretroviral therapy (ART) in Akwa Ibom and Cross River states in Nigeria led to overcrowding at clinics. Patients were devolved to receive ART refills through five differentiated service delivery (DSD) models: fast‐track (FT), adolescent refill clubs (ARCs), community pharmacy ART refill programs (CPARPs), community ART refill clubs (CARCs) and community ART refill groups (CARGs) designed to meet the needs of different groups of PLHIV. In the context of COVID‐19‐related travel restrictions, out‐of‐facility models offered critical mechanisms for continuity of treatment. We compared retention and viral suppression among those devolved to DSD with those who continued standard care at facilities.

Methods

A retrospective cohort study was conducted among patients devolved to DSD from January 2018 to December 2020. Bivariate analyses were conducted to assess differences in retention and viral suppression by socio‐demographic characteristics. Kaplan–Meier assessed retention at 3, 6, 9 and 12 months. Differences in proportions were compared using the chi‐square test; a p‐value of <0.05 was considered significant.

Results

A total of 40,800 PLHIV from 84 facilities received ART through the five models: CARC (53%), FT (19.1%), ARC (12.1%), CPARP (10.4%) and CARG (5.4%). Retention rates at 6 months exceeded 96% for all models compared to 94% among those continuing standard care. Among those using DSD, retention rate at 12 months was higher among adults than children (97.8% vs. 96.7%, p = 0.04). No significant sex differences in retention rates were found among those enrolled in DSD. Viral suppression rates among PLHIV served through DSD were significantly higher among adults than children (95.4% vs. 89.2%; p <0.01). Among adults, 95.4% enrolled in DSD were virally suppressed compared to 91.8% of those in standard care (p <0.01). For children, 89.2% enrolled in DSD were virally suppressed compared to 83.2% in standard care (p <0.01).

Conclusions

PLHIV receiving ART through DSD models had retention but higher viral suppression rates compared to those receiving standard care. Expanding DSD during COVID‐19 has helped ensure uninterrupted access to ART in Nigeria. Further scale‐up is warranted to decongest facilities and improve clinical outcomes.

Patient-Centered, Sustainable Hypertension Care: The Case for Adopting a Differentiated Service Delivery Model for Hypertension Services in Low- and Middle-Income Countries

Expanding hypertension services in low- and middle-income countries requires efficient and effective service delivery approaches that meet the needs and expectations of people living with hypertension within the resource constraints of existing national health systems. Ideally, a hypertension program will extend treatment coverage while maintaining service quality, maximizing efficient resource utilization and improving clinical outcomes. In this article, we discuss lessons learned from HIV differentiated service delivery initiatives, and make the case that the same approach should be adopted for hypertension programs.

Social Support for Self-Care: Patient Strategies for Managing Diabetes and Hypertension in Rural Uganda

Background

Low-income countries suffer a growing burden of non-communicable diseases (NCDs). Self-care practices are crucial for successfully managing NCDs to prevent complications. However, little is known about how patients practice self-care in resource-limited settings.

Objective

We sought to understand self-care efforts and their facilitators among patients with diabetes and hypertension in rural Uganda.

Methods

Between April and June 2019, we conducted a cross-sectional qualitative study among adult patients from outpatient NCD clinics at three health facilities in Uganda. We conducted in-depth interviews exploring self-care practices for hypertension and/or diabetes and used content analysis to identify emergent themes.

Results

Nineteen patients participated. Patients said they preferred conventional medicines as their first resort, but often used traditional medicines to mitigate the impact of inconsistent access to prescribed medicines or as a supplement to those medicines. Patients adopted a wide range of vernacular practices to supplement treatment or replace unavailable diagnostic tests, such as tasting urine to gauge blood-sugar level. Finally, patients sought and received both instrumental and emotional support for self-care activities from networks of family and peers. Patients saw their children as their most reliable source of support facilitating self-care, especially as a source of money for medicines, transport and home necessities.

Conclusion

Patients valued conventional medicines but engaged in varied self-care practices. They depended upon networks of social support from family and peers to facilitate self-care. Interventions to improve self-care may be more effective if they improve access to prescribed medicines and engage or enhance patients' social support networks.

Quality of antiretroviral therapy services in Ghana: Implications for the HIV response in resource-constrained settings

Objective

Number of People Living with Human Immune-deficiency Virus in Ghana is over 300,000 and unmet need for antiretroviral therapy is approximately 60%. This study sought to determine the quality of antiretroviral therapy services in selected ART sites in Ghana using the input-process-outcome approach.

Methods

This is a descriptive cross-sectional case study that employed modified normative evaluation to assess quality of antiretroviral therapy services in the Oti and Volta regions of Ghana among People Living with HIV (n = 384) and healthcare providers (n = 16). The study was conducted from 11 March to 9 May 2019.

Results

Resources for managing HIV clients were largely available with the exception of viral load machines, reagents for CD4 counts, and antifungals such as Fluconazole and Cotrimoxazole. Patients enrolled on antiretroviral therapy within 2 weeks was 71% and clients retained in care within 2 weeks of enrolment was 90%. Approximately 26% of enrolled clients recorded viral load suppression; 33% of People Living with HIV who were not insured with the National Health Insurance Scheme paid for some antiretrovirals and cotrimoxazole. Adherence to ART and Cotrimoxazole were 95% and 88%, respectively, using pill count on their last three visits. Time spent with clinical team was among the worst rated (mean = 2.98, standard deviation = 0.54) quality indicators by patients contrary to interpersonal relationship with health provider which was among the best rated (mean = 3.25, standard deviation = 0.41) indicators.

Conclusion

Observed quality care gaps could potentially reverse gains made in HIV prevention and control in Ghana if not addressed timely; an important value addition of this study is the novel application of input-process-outcome approach in the context of antiretroviral therapy services in Ghana. There is also the need for policy dialogue on inclusion of medications for prophylaxis in antiretroviral therapy on the National Health Insurance Scheme to promote adherence and retention.

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

INTRODUCTION

Many countries in Africa are scaling up differentiated service delivery (DSD) models for HIV treatment, but most existing data systems do not describe the models in use. We surveyed organizations that were supporting DSD models in 2019 in Malawi, South Africa, and Zambia to describe the diversity of DSD models being implemented at that time.

METHODS

We interviewed DSD model implementing organizations for descriptive information about each of the organization's models of care. We described the key characteristics of each model, including population of patients served, location of service delivery, frequency of interactions with patients, duration of dispensing, and cadre(s) of provider involved. To facilitate analysis, we refer to 1 organization supporting 1 model of care as an "organization-model."

RESULTS

The 34 respondents (8 in Malawi, 16 in South Africa, 10 in Zambia) interviewed described a total of 110 organization-models, which included 19 facility-based individual models, 21 out-of-facility-based individual models, 14 health care worker-led groups, and 3 client-led groups; jointly, these encompassed 12 specific service delivery strategies, such as multimonth dispensing, adherence clubs, home delivery, and changes to facility hours. Over two-thirds (n=78) of the organization-models were limited to clinically stable patients. Almost all organization-models (n=96) continued to provide clinical care at established health care facilities; medication pickup took place at facilities, external pickup points, and adherence clubs. Required numbers of provider interactions per year varied widely, from 2 to 12. Dispensing intervals were typically 3 or 6 months in Malawi and Zambia and 2 months in South Africa. Individual models relied more on clinical staff, while group models made greater use of lay personnel.

CONCLUSIONS

As of 2019, there was a large variety of differentiated service models being offered for HIV treatment in Malawi, South Africa, and Zambia, serving diverse patient populations.

Building resource constraints and feasibility considerations in mathematical models for infectious disease: A systematic literature review

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Mathematical model capabilities to explore complex systems now enable priority-setting to consider local resource constraints.

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Common objectives of model-based analyses incorporating constraints are to assess real-world feasibility or allocate resources efficiently.

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Constraints may be incorporated via (i) model-based estimation; (ii) linkage of mathematical and health system models; or (iii) optimisation.

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Models can then project constrained intervention effects and costs and resource requirement s for delivering interventions at full scale.

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'Health system constraints' should be systematically defined for routine operationalisation in model-based priority-setting.

Priority setting for infectious disease control is increasingly concerned with physical input constraints and other real-world restrictions on implementation and on the decision process. These health system constraints determine the ‘feasibility’ of interventions and hence impact. However, considering them within mathematical models places additional demands on model structure and relies on data availability. This review aims to provide an overview of published methods for considering constraints in mathematical models of infectious disease.

We systematically searched the literature to identify studies employing dynamic transmission models to assess interventions in any infectious disease and geographical area that included non-financial constraints to implementation. Information was extracted on the types of constraints considered and how these were identified and characterised, as well as on the model structures and techniques for incorporating the constraints.

A total of 36 studies were retained for analysis. While most dynamic transmission models identified were deterministic compartmental models, stochastic models and agent-based simulations were also successfully used for assessing the effects of non-financial constraints on priority setting. Studies aimed to assess reductions in intervention coverage (and programme costs) as a result of constraints preventing successful roll-out and scale-up, and/or to calculate costs and resources needed to relax these constraints and achieve desired coverage levels. We identified three approaches for incorporating constraints within the analyses: (i) estimation within the disease transmission model; (ii) linking disease transmission and health system models; (iii) optimising under constraints (other than the budget).

The review highlighted the viability of expanding model-based priority setting to consider health system constraints. We show strengths and limitations in current approaches to identify and quantify locally-relevant constraints, ranging from simple assumptions to structured elicitation and operational models. Overall, there is a clear need for transparency in the way feasibility is defined as a decision criteria for its systematic operationalisation within models.

"Dispense antiretrovirals daily!" restructuring the delivery of HIV services to optimize antiretroviral initiation among men in Malawi

BACKGROUND

Gender disparities exist in the scale-up and uptake of HIV services with men being disproportionately under-represented in the services. In Eastern and Southern Africa, of the people living with HIV infection, more adult women than men were on treatment highlighting the disparities in HIV services. Delayed initiation of antiretroviral treatment creates a missed opportunity to prevent transmission of HIV while increasing HIV and AIDS-associated morbidity and mortality. The main objective of this study was to assess the strategies that men prefer for Antiretroviral Therapy (ART) initiation in Blantyre, Malawi.

METHODS

This was a qualitative study conducted in 7 Health facilities in Blantyre from January to July 2017. We selected participants following purposive sampling. We conducted 20 in-depth interviews (IDIs) with men of different HIV statuses, 17 interviews with health care workers (HCWs), and 14 focus group discussions (FGDs) among men of varying HIV statuses. We digitally recorded all the data, transcribed verbatim, managed using NVivo, and analysed it thematically.

RESULTS

Restructuring the delivery of antiretroviral (ARVs) treatment and conduct of ART clinics is key to optimizing early initiation of treatment among heterosexual men in Blantyre. The areas requiring restructuring included: Clinic days by offering ARVs daily; Clinic hours to accommodate schedules of men; Clinic layout and flow that preserves privacy and establishment of male-specific clinics; ARV dispensing procedures where clients receive more pills to last them longer than 3 months. Additionally there is need to improve the packaging of ARVs, invent ARVs with less dosing frequency, and dispense ARVs from the main pharmacy. It was further suggested that the test-and-treat strategy be implemented with fidelity and revising the content in counseling sessions with an emphasis on the benefits of ARVs.

CONCLUSION

The success in ART initiation among men will require a restructuring of the current ART services to make them accessible and available for men to initiate treatment. The inclusion of people-centered approaches will ensure that individual preferences are incorporated into the initiation of ARVs. The type, frequency, distribution, and packaging of ARVs should be aligned with other medicines readily available within a health facility to minimize stigma.

Provider and Patient Perspectives of Rapid ART Initiation and Streamlined HIV Care: Qualitative Insights From Eastern African Communities

The Sustainable East Africa Research in Community Health (SEARCH), a universal test and treat (UTT) trial, implemented 'Streamlined Care'-a multicomponent strategy including rapid linkage to care and antiretroviral therapy (ART) start, 3-monthly refills, viral load counseling, and accessible, patient-centered care provision. To understand patient and provider experiences of Streamlined Care to inform future care innovations, we conducted in-depth interviews with patients (n = 18) and providers (n = 28) at baseline (2014) and follow-up (2015) (n = 17 patients; n = 21 providers). Audio recordings were transcribed, translated, and deductively and inductively coded. Streamlined Care helped to decongest clinic spaces and de-stigmatize human immunodeficiency virus (HIV) care. Patients credited the individualized counselling, provider-assisted HIV status disclosure, and providers' knowledge of patient's drug schedules, availability, and phone call reminders for their care engagement. However, for some, denial (repeated testing to disprove HIV+ results), feeling healthy, limited understanding of the benefits of early ART, and anticipated side-effects, and mistrust of researchers hindered rapid ART initiation. Patients' short and long-term mobility proved challenging for both patients and providers. Providers viewed viral load counselling as a powerful tool to convince otherwise healthy and high-CD4 patients to initiate ART. Patient-centered HIV care models should build on the successes of Streamlined Care, while addressing persistent barriers.#NCT01864683-https://clinicaltrials.gov/ct2/show/NCT01864603.

Universal test and treat in relation to HIV disease progression: results from a stepped-wedge trial in Eswatini

OBJECTIVES

Universal test and treat (UTT) is recommended for people living with HIV (PLHIV) to reduce morbidity/mortality and minimize transmission. However, concerns exist that this strategy may lead to more crowded hospitals, longer wait times and poorer service, adversely impacting health outcomes for clients with severe disease. We assessed how UTT was related to markers of disease progression in PLHIV overall and specifically among clients with low CD4 count/high World Health Organization (WHO) stage.

METHODS

The analysis was conducted using data from a stepped-wedge trial of UTT in 14 government-managed health facilities in Eswatini from 2014 to 2017. Disease progression was defined as CD4 count falling below 200 cells/µL or baseline value, > 10% weight loss, body mass index (BMI) dropping below 18.5, incident tuberculosis (TB) or HIV-related death; these outcomes also were assessed individually. We assessed multivariate Cox proportional hazard models overall and specifically among clients with CD4 count < 350 cells/μL or WHO stage 3-4 at enrolment.

RESULTS

Eight hundred and seven of 3176 clients demonstrated at least one marker of disease progression over 2339 person-years of follow-up. Overall, 62.4% of clients were female; 57.2% were < 35 years old. Compared to clients not exposed to UTT, those exposed to UTT had a lower rate of disease progression overall [adjusted hazard ratio (aHR) 0.60; 95% confidence interval (CI) 0.46-0.78] and a lower rate of CD4 decline (aHR 0.40; 95% CI 0.27-0.58). When the analysis was limited to clients with CD4 count < 350 cells/μL or WHO stage 3-4, UTT was not associated with disease progression (aHR 0.92; 95% CI 0.66-1.29).

CONCLUSIONS

UTT reduced HIV disease progression overall and was not detrimental for clients with more severe disease.

Antiretroviral therapy in community pharmacies - Implementation and outcomes of a differentiated drug delivery model in Nigeria

INTRODUCTION

The World Health Organization recommended differentiated models of care portends opportunities to decongest hospitals providing antiretroviral therapy (ART) and improve retention, especially in developing countries. A community pharmacy-based ART refill model was implemented where stable clients were devolved to community pharmacies for routine refills at a service fee, to promote private sector participation and sustainability of ART services. The aim of this study was to assess the feasibility, acceptability and outcomes of this model in Nigeria.

METHODS

A population-based retrospective analysis of the community pharmacy ART refill program of the United States Agency for International Development-funded 'Strengthening Integrated Delivery of HIV/AIDS Services' project in Lagos, Rivers, Cross River and Akwa Ibom States from October 2016 to February 2018 was conducted. Standard descriptive statistical methods were used for baseline demographic and clinical characteristics of study participants. Outcomes were assessed using the Chi-square test and a multivariate logistic regressions model. Statistical significance was defined at α-level of 0.05. Analyses were performed using SPSS for Windows version 23 (IBM Corp, Armonk, USA).

RESULTS

A total of 10015 participants representing 14.4% of ART clients in 50 hospitals opted for this model and were devolved to 244 community pharmacies. All clients consented and paid a service fee of N1000 (about $3) per refill visit. Median follow-up duration was 6 months. Prescription refill rate was 95% (95% CI 94.2-95.3). Retention rate was 98% while viral suppression was 99.12%. Refill rates were significantly affected by ART duration, regimen, age and location (P < 0.001, 0.004, 0.034 and < 0.001 respectively).

CONCLUSIONS

This community pharmacy ART refill model of differentiated care is feasible and acceptable by clients and providers and demonstrated excellent clinical outcomes of retention and viral suppression. The ability and willingness of some clients to contribute financially to their HIV care was also demonstrated.

Community-based adherence clubs for postpartum women on antiretroviral therapy (ART) in Cape Town, South Africa: a pilot study

BACKGROUND

With an increasing number of countries implementing Option B+ guidelines of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, there is urgent need to identify effective approaches for retaining this growing and highly vulnerable population in ART care.

METHODS

Newly postpartum, breastfeeding women who initiated ART in pregnancy and met eligibility criteria were enrolled, and offered the choice of two options for postpartum ART care: (i) referral to existing network of community-based adherence clubs or (ii) referral to local primary health care clinic (PHC). Women were followed at study measurement visits conducted separately from either service. Primary outcome was a composite endpoint of retention in ART services and viral suppression [VS < 50 copies/mL based on viral load (VL) testing at measurement visits] at 12 months postpartum. Outcomes were compared across postpartum services using chi-square, Fisher's exact tests and Poisson regression models. The primary outcome was compared across services where women were receiving care at 12 months postpartum in exploratory analyses.

RESULTS

Between February and September 2015, 129 women (median age: 28.9 years; median time postpartum: 10 days) were enrolled with 65% opting to receive postpartum HIV care through an adherence club. Among 110 women retained at study measurement visits, 91 (83%) achieved the composite endpoint, with no difference between those who originally chose clubs versus those who chose PHC services. Movement from an adherence club to PHC services was common: 31% of women who originally chose clubs and were engaged in care at 12 months postpartum were attending a PHC service. Further, levels of VS differed significantly by where women were accessing ART care at 12 months postpartum, regardless of initial choice: 98% of women receiving care in an adherence club and 76% receiving care at PHC had VS < 50 copies/mL at 12 months postpartum (p = 0.001).

CONCLUSION

This study found comparable outcomes related to retention and VS at 12 months postpartum between women choosing adherence clubs and those choosing PHC. However, movement between postpartum services among those who originally chose adherence clubs was common, with poorer VS outcomes among women leaving clubs and returning to PHC services.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02417675 , April 16, 2015 (retrospectively registered).

Accessing medicines for non-communicable diseases: Patients and health care workers' experiences at public and private health facilities in Uganda

Background

Non-communicable diseases (NCDs) are increasingly prevalent in low- and middle-income countries. Successful management requires consistent access to appropriate medicines. Availability of NCD medicines is generally low, especially in the public sector, however, little is known about other factors affecting access. We explored barriers and facilitators of access to medicines for diabetes and hypertension at public and private health facilities in Uganda.

Methods

We conducted a qualitative descriptive study at six public hospitals and five private health facilities in different regions of Uganda. Data collection included 36 in-depth interviews and 14 focus group discussions (n = 128) among purposively selected adult outpatients with diabetes and/or hypertension and 26 key informant interviews with healthcare workers and patient association leaders. Transcripts were coded and emerging themes identified using the Framework method.

Results

Four main themes emerged: Stocking of medicines and supplies, Financial factors, Individual behaviour and attitudes, and Service delivery at health facilities. Stocking of medicines and supplies mainly presented barriers to access at public facilities including frequent stockouts, failure to stock certain medicines and low quality brands often rejected by patients. Financial factors, especially high cost of medicines and limited insurance coverage, were barriers in private facilities. Free service provision was a facilitator at public facilities. Patients’ confusion resulting from mixed messages and their preference for herbal treatments were cross-sector barriers. While flexibility in NCD service provision was a facilitator at private facilities, provider burnout and limited operating hours were barriers in public facilities. Patient-driven associations exist at some public facilities and help mitigate inadequate medicine stock.

Conclusion

Access to NCD medicines in Uganda is influenced by both health system and patient factors. Some factors are sector-specific, while others cross-cutting between public and private sectors. Due to commonalities in barriers, potential strategies for overcoming them may include patient-driven associations, public-private partnerships, and multi-modal health education platforms.

Will differentiated care for stable HIV patients reduce healthcare systems costs?

INTRODUCTION

South Africa's National Department of Health launched the National Adherence Guidelines for Chronic Diseases in 2015. These guidelines include adherence clubs (AC) and decentralized medication delivery (DMD) as two differentiated models of care for stable HIV patients on antiretroviral therapy. While the adherence guidelines do not suggest that provider costs (costs to the healthcare system for medications, laboratory tests and visits to clinics or alternative locations) for stable patients in these differentiated models of care will be lower than conventional, clinic-based care, recent modelling exercises suggest that such differentiated models could substantially reduce provider costs. In the context of continued implementation of the guidelines, we discuss the conditions under which provider costs of care for stable HIV patients could fall, or rise, with AC and DMD models of care in South Africa.

DISCUSSION

In prior studies of HIV care and treatment costs, three main cost categories are antiretroviral medications, laboratory tests and general interaction costs based on encounters with health workers. Stable patients are likely to be on the national first-line regimen (Tenofovir/Entricitabine/Efavarinz (TDF/FTC/EFV)), so no difference in the costs of medications is expected. Laboratory testing guidelines for stable patients are the same regardless of the model of care, so no difference in laboratory costs is expected as well. Based on existing information regarding the costs of clinic visits, AC visits and DMD drug pickups, we expect that for some clinics, visit costs for DMD or AC models of care could be less, but modestly so, than for conventional, clinic-based care. For other clinics, however, DMD or AC models could have higher visit costs (see Table 2).

CONCLUSIONS

The standard of care for stable patients has already been "differentiated" for years in South Africa, prior to the roll out of the new adherence guidelines. AC and DMD models of care, when implemented as envisioned in the guidelines, are unlikely to generate substantive reductions or increases in provider costs of care.

A Review of Differentiated Service Delivery for HIV Treatment: Effectiveness, Mechanisms, Targeting, and Scale

PURPOSE OF REVIEW

Differentiated service delivery (DSD) models were initially developed as a means to combat suboptimal long-term retention in HIV care, and to better titrate limited health systems resources to patient needs, primarily in low-income countries. The models themselves are designed to streamline care along the HIV care cascade and range from individual to group-based care and facility to community-based health delivery systems. However, much remains to be understood about how well and for whom DSD models work and whether these models can be scaled, are sustainable, and can reach vulnerable and high-risk populations. Implementation science is tasked with addressing some of these questions through systematic, scientific inquiry. We review the available published evidence on the implementation of DSD and suggest further health systems innovations needed to maximize the public health impact of DSD and future implementation science research directions in this expanding field.

RECENT FINDINGS

While early observational data supported the effectiveness of various DSD models, more recently published trials as well as evaluations of national scale-up provide more rigorous evidence for effectiveness and performance at scale. Deeper understanding of the mechanism of effect of various DSD models and generalizability of studies to other countries or contexts remains somewhat limited. Relative implementability of DSD models may differ based on patient preference, logistical complexity of model adoption and maintenance, human resource and pharmacy supply chain needs, and comparative cost-effectiveness. However, few studies to date have evaluated comparative implementation or cost-effectiveness from a health systems perspective. While DSD represents an exciting and promising "next step" in HIV health care delivery, this innovation comes with its own set of implementation challenges. Evidence on the effectiveness of DSD generally supports the use of most DSD models, although it is still unclear which models are most relevant in diverse settings and populations and which are the most cost-effective. Challenges during scale-up highlight the need for accurate differentiation of patients, sustainable inclusion of a new cadre of health care worker (the community health care worker), and substantial strengthening of existing pharmacy supply chains. To maximize the public health impact of DSD, systems need to be patient-centered and adaptive, as well as employ robust quality improvement processes.

Can Changes in Service Delivery Models Improve Program Quality and Efficiency? A Closer Look at HIV Programs in Kenya and Uganda

Supplemental Digital Content is Available in the Text.

With the scale-up of antiretroviral treatment, many health facilities in low- and middle-income countries have implemented innovative practices targeted at overcoming operational challenges and delivering efficient quality HIV services. However, many of these practices remain largely unexplored as a means to better reach the global 90-90-90 targets.

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

INTRODUCTION

Multimonth dispensing (MMD) of antiretroviral therapy (ART) is a differentiated model of care that can help overcome health system challenges and reduce the burden of HIV care on clients. Although 3-month dispensing has been the standard of care, interest has increased in extending refill intervals to 6 months. We explored client and provider experiences with MMD in Malawi as part of a cluster randomized trial evaluating 3- versus 6-month ART dispensing.

METHODS

Semi-structured in-depth interviews were conducted with 17 ART providers and 62 stable, adult clients with HIV on ART. Clients and providers were evenly divided by arm and were eligible for an interview if they had been participating in the study for 1 year (clients) or 6 months (providers). Questions focused on perceived challenges and benefits of the 3- or 6-month amount of ART dispensing. Interviews were transcribed, and data were coded and analyzed using constant comparison.

RESULTS

Both clients and providers reported that the larger medication supply had benefits. Clients reported decreased costs due to less frequent travel to the clinic and increased time for income-generating activities. Clients in the 6-month dispensing arm reported a greater sense of personal freedom and normalcy. Providers felt that the 6-month dispensing interval reduced their workload. They also expressed concerned about clients' challenges with ART storage at home, but clients reported no storage problems. Although providers mentioned the potential risk of clients sharing the larger medication supply with family or friends, clients emphasized the value of ART and reported only rare, short-term sharing, mostly with their spouses. Providers mentioned clients' lack of motivation to seek care for illnesses that might occur between refill appointments.

CONCLUSIONS

The 6-month ART dispensing arm was particularly beneficial to clients for decreased costs, increased time for income generation, and a greater sense of normalcy. Providers' concerns about storage, sharing, and return visits to the facility did not emerge in client interviews. Further data are needed on the feasibility of implementing a large-scale program with 6-month dispensing.

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

BACKGROUND

Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)'s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients' and HIV service managers' perspectives on barriers to implementation of Differentiated ART service delivery in Uganda.

METHODS

We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context.

RESULTS

Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations.

CONTEXT

Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups.

CONCLUSION

This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

Super learner analysis of real-time electronically monitored adherence to antiretroviral therapy under constrained optimization and comparison to non-differentiated care approaches for persons living with HIV in rural Uganda

INTRODUCTION

Real-time electronic adherence monitoring (EAM) systems could inform on-going risk assessment for HIV viraemia and be used to personalize viral load testing schedules. We evaluated the potential of real-time EAM (transferred via cellular signal) and standard EAM (downloaded via USB cable) in rural Uganda to inform individually differentiated viral load testing strategies by applying machine learning approaches.

METHODS

We evaluated an observational cohort of persons living with HIV and treated with antiretroviral therapy (ART) who were monitored longitudinally with standard EAM from 2005 to 2011 and real-time EAM from 2011 to 2015. Super learner, an ensemble machine learning method, was used to develop a tool for targeting viral load testing to detect viraemia (>1000 copies/ml) based on clinical (CD4 count, ART regimen), viral load and demographic data, together with EAM-based adherence. Using sample-splitting (cross-validation), we evaluated area under the receiver operating characteristic curve (cvAUC), potential for EAM data to selectively defer viral load tests while minimizing delays in viraemia detection, and performance compared to WHO-recommended testing schedules.

RESULTS

In total, 443 persons (1801 person-years) and 485 persons (930 person-years) contributed to standard and real-time EAM analyses respectively. In the 2011 to 2015 dataset, addition of real-time EAM (cvAUC: 0.88; 95% CI: 0.83, 0.93) significantly improved prediction compared to clinical/demographic data alone (cvAUC: 0.78; 95% CI: 0.72, 0.86; p = 0.03). In the 2005 to 2011 dataset, addition of standard EAM (cvAUC: 0.77; 95% CI: 0.72, 0.81) did not significantly improve prediction compared to clinical/demographic data alone (cvAUC: 0.70; 95% CI: 0.64, 0.76; p = 0.08). A hypothetical testing strategy using real-time EAM to guide deferral of viral load tests would have reduced the number of tests by 32% while detecting 87% of viraemia cases without delay. By comparison, the WHO-recommended testing schedule would have reduced the number of tests by 69%, but resulted in delayed detection of viraemia a mean of 74 days for 84% of individuals with viraemia. Similar rules derived from standard EAM also resulted in potential testing frequency reductions.

CONCLUSIONS

Our machine learning approach demonstrates potential for combining EAM data with other clinical measures to develop a selective testing rule that reduces number of viral load tests ordered, while still identifying those at highest risk for viraemia.

Smart cascades: using cost analysis to improve HIV care and treatment interventions to achieve global 95-95-95 goals

Background: HIV programmes are achieving significant scale, even as external financing plateaus. Maximising achievement from identification to viral suppression is key to epidemic control and reaching global 95-95-95 goals. Cost and technical efficiency analyses can help programs understand why losses occur along the cascade, which tactics prevent losses, and additional investments required for cost-efficient solutions.Methodology: The PEPFAR- and USAID-funded Health Policy Plus (HP+) project identified cascade failure points and interventions needed in six countries (Ghana, Indonesia, Kyrgyz Republic, Kenya, Tajikistan, Tanzania). Methods included secondary data analysis and expert interviews. HP+ estimated unit costs and effectiveness of tactics to model future costs and cascade outcomes across scenarios. Conclusions across countries are synthesised for overall best practices.Results: In Ghana, Indonesia, Tajikistan, and the Kyrgyz Republic, HIV identification strategies need to evolve to counter diminishing testing yields. Higher-yield testing modes may have higher costs per person tested, yet lower costs per person identified compared to previous strategies. In Kenya, investments in linkage and retention require additional funding, and will reduce the need for expensive loss-to-follow-up activities. In Tanzania, differentiated antiretroviral therapy can improve patient management while reducing facility-level costs.Conclusion: Results from diverse settings suggest that cost-efficiency analyses aimed at smart cascades will help countries identify and resolve reasons for poor outcomes. The analyses are predicated on contextual exploration of how interventions are linked, and should inform prioritisation and investment strategies. While improving the cascade often has incremental costs, it may be cost-efficient versus the long-term cost of poor outcomes.

Differentiated service delivery: navigating the path to scale

PURPOSE OF REVIEW

Differentiated service delivery (DSD) has emerged as an approach for HIV programs seeking to better serve the needs of people living with HIV, reduce unnecessary burdens on the health system, and improve client outcomes. We reviewed recent evidence that addresses the challenge of DSD scale-up.

RECENT FINDINGS

Most current evidence focuses on treatment of clinically stable adult clients in high HIV prevalence settings. Nonetheless, a growing body of research is emerging on how the concept of differentiation is being applied to HIV testing, linkage, and initiation; service delivery to specific demographic groups including key populations - MSM, people who inject drugs, people in prisons, sex workers, and transgender people; service delivery to adolescents and pregnant women; and impact on related medical conditions like advanced HIV. There is also an increasing emphasis on measuring client experience. Key barriers to scale-up include the capacity of monitoring and evaluation systems, access to viral load monitoring and funding for community-led demand generation efforts. Another barrier is the lack of sufficient data to evaluate the various manifestations of the DSD model.

SUMMARY

Emerging evidence is providing welcome nuance to the discourse on the concept of DSD for HIV. The challenge will be taking evolving DSD concepts from pilot to scale. Countries must review their particular context, define the expected needs of their clients in different settings, introduce appropriate models - and be willing to adjust programming based on quantitative and qualitative outcomes.

Differentiated models of service delivery for antiretroviral treatment of HIV in sub-Saharan Africa: a rapid review protocol

BACKGROUND

To meet global targets for the treatment of HIV, high-prevalence countries are launching or expanding differentiated models of service delivery (DSD) for antiretroviral therapy (ART). Ongoing studies report on metrics specific to individual models of care, but little is known about the overall scale, impact, costs, and benefits of widespread implementation of DSD. We will conduct a rapid review of recent literature on DSD currently in use in sub-Saharan Africa and identify gaps in the literature with respect to the description of delivery models, coverage, effectiveness, and cost.

METHODS

We will use an adapted version of the preferred reporting items for systematic reviews and meta-analysis protocols (PRISMA-P) for reporting. To avoid repeating earlier reviews, only sources reporting data on interventions conducted and/or patients starting antiretroviral treatment since 1 January 2016 will be included. Other inclusion criteria: must report on HIV-positive patients receiving antiretroviral therapy (ART) for the treatment of HIV/AIDS in sub-Saharan Africa; must describe an antiretroviral care intervention and identify the location, visit frequency, provider, patient group, and intervention intensity; and must report at least one of the following outcomes: population coverage, intervention uptake, treatment outcomes, cost or resource allocation, acceptability, or feasibility.

EXCLUSION CRITERIA

receiving ART as part of prevention of mother-to-child transmission (PMTCT) program or receiving preventive ART (PEP or PrEP). This review will include peer-reviewed articles and conference abstracts. Publication databases to be searched include PubMed, EMBASE, and Web of Science. For analysis, where possible, we will group the DSD by key characteristics (e.g., population served, visit frequency, visit location) and then report means and/or medians of coverage and outcomes with confidence intervals or IQRs. We will also descriptively compare and contrast different models of care, implementation challenges, and other non-quantitative information.

DISCUSSION

This review will provide an initial picture of the status quo for the implementation of DSD in sub-Saharan Africa and identify directions for research and implementation support in the future. This big-picture analysis will be useful for ministries of health, implementers, and donor agencies to inform decision-making on DSD scale-up.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42019118230.

Cost of Differentiated HIV Antiretroviral Therapy Delivery Strategies in Sub-Saharan Africa: A Systematic Review

BACKGROUND

Efficient and scalable models for HIV treatment are needed to maximize health outcomes with available resources. By adapting services to client needs, differentiated antiretroviral therapy (DART) has the potential to use resources more efficiently. We conducted a systematic review assessing the cost of DART in sub-Saharan Africa compared with the standard of care.

METHODS

We searched PubMed, Embase, Global Health, EconLit, and the grey literature for studies published between 2005 and 2019 that assessed the cost of DART. Models were classified as facility-vs. community-based and individual- vs group-based. We extracted the annual per-patient service delivery cost and incremental cost of DART compared with standard of care in 2018 USD.

RESULTS

We identified 12 articles that reported costs for 16 DART models in 7 countries. The majority of models were facility-based (n = 12) and located in Uganda (n = 7). The annual cost per patient within DART models (excluding drugs) ranged from $27 to $889 (2018 USD). Of the 11 models reporting incremental costs, 7 found DART to be cost saving. The median incremental saving per patient per year among cost-saving models was $67. Personnel was the most common driver of reduced costs, but savings were sometimes offset by higher overheads or utilization.

CONCLUSIONS

DART models can save personnel costs by task shifting and reducing visit frequency. Additional economic evidence from community-based and group models is needed to better understand the scalability of DART. To decrease costs, programs will need to match DART models to client needs without incurring substantial overheads.

Inflammatory biomarkers prior to antiretroviral therapy as prognostic markers of 12-month mortality in South Africa and Uganda

OBJECTIVE

The aim of this study was to determine the utility of biomarkers of immune activation, systemic inflammation and coagulopathy prior to antiretroviral therapy to predict mortality during the first year of antiretroviral therapy (ART) in sub-Saharan Africa.

DESIGN

A prospective, observational cohort.

METHODS

We measured soluble CD14, interleukin-6 and D-dimer in nonpregnant individuals initiating ART in South Africa and Uganda in the Measuring Early Treatment Adherence (META) Study. We used survival analysis methods to estimate their association with 12-month mortality, and fit receiver operator curves (ROC) to assess the prognostic value of each biomarker.

RESULTS

Six-hundred and sixty individuals were enrolled and had pretreatment biomarkers measured. Approximately 60% were women, with a median CD4 cell count of 187 cells/μl [interquartile range (IQR) 111-425] and approximately half were enrolled each from South Africa and Uganda. We observed 34 deaths for a crude mortality of 5.3 deaths/100 person-years (py) (95% confidence interval 3.8-7.4), which ranged from 0/100 py to 13.7/100 py in the lowest and highest tertile of pretreatment sCD14, respectively. In Cox models, all three biomarkers were strongly predictive of the hazard of death (adjusted hazard ratio 3-6, all P < 0.01). In multivariable models including biomarkers, both pretreatment CD4 cell count and pretreatment viral load became borderline or nonsignificantly associated with mortality. The c-statistic for area under ROC was higher for all three biomarkers than for CD4 cell count (P < 0.01).

CONCLUSION

Biomarkers of immune activation, systemic inflammation and coagulopathy prior to ART initiation are strongly predictive of early death on treatment after adjustment for CD4 cell count. Such biomarkers might serve as important prognostic indicators for patient triage in this population.

Stated-preference research in HIV: A scoping review

Discrete choice experiments (DCE), conjoint analysis (CA), and best-worst scaling (BWS) are quantitative techniques for estimating consumer preferences for products or services. These methods are increasingly used in healthcare research, but their applications within the field of HIV research have not yet been described. The objective of this scoping review was to systematically map the extent and nature of published DCE, CA, and BWS studies in the field of HIV and identify priority areas where these methods can be used in the future. Online databases were searched to identify published HIV-related DCE, CA and BWS studies in any country and year as the primary outcome. After screening 1,496 citations, 57 studies were identified that were conducted in 26 countries from 2000-2017. The frequency of published studies increased over time and covered HIV themes relating to prevention (n = 25), counselling and testing (n = 10), service delivery (n = 10), and antiretroviral therapy (n = 12). Most studies were DCEs (63%) followed by CA (37%) and BWS (4%). The median [IQR] sample size was 288 [138-496] participants, and 74% of studies used primary qualitative data to develop attributes. Only 30% of studies were conducted in sub-Saharan Africa where the burden of HIV is highest. Moreover, few studies surveyed key populations including men who have sex with men, transgender people, pregnant and postpartum women, adolescents, and people who inject drugs. These populations represent priorities for future stated-preference research. This scoping review can help researchers, policy makers, program implementers, and health economists to better understand the various applications of stated-preference research methods in the field of HIV.

Tailored HIV programmes and universal health coverage

Improvements in geospatial health data and tailored human immunodeficiency virus (HIV) testing, prevention and treatment have led to greater microtargeting of the HIV response, based on location, risk, clinical status and disease burden. These approaches show promise for achieving control of the HIV epidemic. At the same time, United Nations Member States have committed to achieving broader health and development goals by 2030, including universal health coverage (UHC). HIV epidemic control will facilitate UHC by averting the need to commit ever-increasing resources to HIV services. Yet an overly targeted HIV response could also distort health systems, impede integration and potentially threaten broader health goals. We discuss current approaches to achieving both UHC and HIV epidemic control, noting potential areas of friction between disease-specific microtargeting and integrated health systems, and highlighting opportunities for convergence that could enhance both initiatives. Examples of these programmatic elements that could be better aligned include: improved information systems with unique identifiers to track and monitor individuals across health services and the life course; strengthened subnational data use; more accountable supply chains that supply a broad range of services; and strengthened community-based services and workforces. We argue that the response both to HIV and to broader health threats should use these areas of convergence to increase health systems efficiency and mitigate the harm of any potential decrease in health funding. Further investments in implementation and monitoring of these programme elements will be needed to make progress towards both UHC and HIV epidemic control.

Differentiated Antiretroviral Therapy Distribution Models: Enablers and Barriers to Universal HIV Treatment in South Africa, Uganda, and Zimbabwe

Emerging HIV treatment distribution models across sub-Saharan Africa seek to overcome barriers to attaining antiretroviral therapy and to strengthen adherence in people living with HIV. We describe enablers, barriers, and benefits of differentiated treatment distribution models in South Africa, Uganda, and Zimbabwe. Data collection included semistructured interviews and focus group discussions with 163 stakeholders from policy, program, and patient levels. Four types of facility-based and 3 types of community-based models were identified. Enablers included policy, leadership, and guidance; functional information systems; strong care linkages; steady drug supply; patient education; and peer support. Barriers included insufficient drug supply, stigma, discrimination, and poor care linkages. Benefits included perceived improved adherence, peer support, reduced stigma and discrimination, increased time for providers to spend with complex patients, and travel and cost savings for patients. Differentiated treatment distribution models can enhance treatment access for patients who are clinically stable.

VIBRA trial - Effect of village-based refill of ART following home-based same-day ART initiation vs clinic-based ART refill on viral suppression among individuals living with HIV: protocol of a cluster-randomized clinical trial in rural Lesotho

BACKGROUND

There is a need for evaluating community-based antiretroviral therapy (ART) delivery models to improve overall performance of HIV programs, specifically in populations that may have difficulties to access continuous care. This cluster-randomized clinical trial aims to evaluate the effectiveness of a multicomponent differentiated ART delivery model (VIBRA model) after home-based same-day ART initiation in remote villages in Lesotho, southern Africa.

METHODS/DESIGN

The VIBRA trial (VIllage-Based Refill of ART) is a cluster-randomized parallel-group superiority clinical trial conducted in two districts in Lesotho, southern Africa. Clusters (i.e., villages) are randomly assigned to either the VIBRA model or standard care. The clusters are stratified by district, village size, and village access to the nearest health facility. Eligible individuals (HIV-positive, aged 10 years or older, and not taking ART) identified during community-based HIV testing campaigns are offered same-day home-based ART initiation. The intervention clusters offer a differentiated ART delivery package with two features: (1) drug refills and follow-ups by trained and supervised village health workers (VHWs) and (2) the option of receiving individually tailored adherence reminders and notifications of viral load results via SMS. The control clusters will continue to receive standard care, i.e., collecting ART refills from a clinic and no SMS notifications. The primary endpoint is viral suppression 12 months after enrolment. Secondary endpoints include linkage to and engagement in care. Furthermore, safety and cost-effectiveness analyses plus qualitative research are planned. The minimum target sample size is 262 participants. The statistical analyses will follow the CONSORT guidelines. The VIBRA trial is linked to another trial, the HOSENG (HOme-based SElf-testiNG) trial, both of which are within the GET ON (GETing tOwards Ninety) research project.

DISCUSSION

The VIBRA trial is among the first to evaluate the delivery of ART by VHWs immediately after ART initiation. It assesses the entire HIV care cascade from testing to viral suppression. As most countries in sub-Saharan Africa have cadres like the VHW program in Lesotho, this model-if shown to be effective-has the potential to be scaled up. The system impact evaluation will provide valuable cost estimations, and the qualitative research will suggest how the model could be further modified to optimize its impact.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03630549 . Registered on 15 August 2018.