Healthcare providers and people with HIV in Uganda prefer clinic-based models of simplified HIV care to community-based models, Ugandan researchers report in the journal PLOS ONE. Convenience, confidentiality and contact with healthcare workers were judged more important to clients, so that clinic-based drug refill had been more widely adopted than other forms of differentiated service delivery, the study found.
Clinic-based models were also judged to be cheaper and easier to implement than community-based models.
Differentiated service delivery models for HIV care are designed to make more efficient use of health system resources by reducing healthcare visits in general, and tests for people on stable antiretroviral therapy (ART) in particular. The service models allow people with HIV to pick up HIV medication less frequently, attend fewer clinic appointments and travel shorter distances for care.
National HIV treatment programmes have been encouraged to adopt differentiated service delivery models by the World Health Organization and major donors such as PEPFAR and the Global Fund. Uganda began to implement differentiated service delivery models in 2017. They have already proved to result in fewer periods off antiretroviral (ARV) therapy.
Uganda’s Health Ministry has promoted the adoption of five models of differentiated delivery of antiretroviral treatment, the first three for people on stable antiretroviral treatment with suppressed viral load:
- Fast track drug refill: collecting 3-6 month supplies of ARVs from health facilities
- Community client-led ART delivery: six people with HIV form a group and rotate in picking up ART refills
- Community drug distribution points: outreach sites in communities are designated as ART pick-up sites
- Facility-based (i.e. clinic-based) group: adherence support groups based at healthcare facilities for people requiring additional adherence support
- Facility-based individual management: more intensive care with more frequent appointments for people starting ART, with multiple health conditions, or who have developed an unsuppressed viral load.
Dr Henry Zakumumpa of Makere University and colleagues carried out a mixed-methods study in 2019 and 2020 to investigate which models had been adopted more frequently and why.
The first stage of the study surveyed the adoption of differentiated ART delivery in 195 health facilities evenly distributed across five rural and five urban health districts. One hundred and sixteen facilities responded to the survey. Sixty-eight health facilities were publicly funded, 27 were private not-for-profit and 21 were private for-profit. The majority (61%) were urban facilities, and most were either sub-district or sub-county health centres (75%) rather than hospitals. Approximately two-thirds were providing care for at least 500 people on ART.
A majority of facilities began to implement differentiated service delivery in 2018 (57%) but a small proportion (10%) had not begun implementation by the time of the study. The most common forms of differentiated service delivery were fast track drug refill (86% of facilities offered this) and facility-based groups (offered by 72%). Community client-led ART delivery had been adopted by 54% of facilities. Community drug distribution points were less common, offered by 25% of facilities.
Only one in four facilities had implemented all five recommended models and almost half of these were private not-for-profit facilities (predominantly faith-based). More than half were general hospitals.
Private for-profit facilities were least likely to have implemented differentiated service delivery. Only seven out of 21 facilities had implemented any intervention at all by 2019, compared to 67% of public facilities and 52% of private not-for-profit facilities who adopted at least one model in 2018 alone.
In the second stage of the study, the researchers interviewed 16 facility managers and carried out focus groups with 56 healthcare workers, to learn more about the reasons for choosing specific models and lack of implementation.
It was clear that cost and convenience for the facility had a major influence on the types of models adopted. Community-based drug distribution points were less attractive than community client-led drug distribution because the costs of organising drug distribution and transporting drugs to the distribution point were borne by the health facility. Community client-led drug distribution required people with HIV to meet the costs of travel to the facility to pick up medication and organise distribution.
The healthcare workers told the researchers, however, that community delivery models were unpopular with clients because they forced them to identify themselves as HIV positive to other people living with HIV. They feared disclosure of their HIV status and stigmatisation in their community. Community groups were more likely to be composed of women and tended to be avoided by men.
In urban settings, convenience was another factor influencing client preferences. Fast track drug refill was preferred to community client-led drug distribution because it required less commitment of time. But in rural areas, some clients saw community client-led drug distribution as preferable because it reduced individual travel costs by pooling the cost of collecting medication.
Client preference for an interaction with a healthcare worker also contributed to a preference for facility-based models.
Fast track drug refill was seen as the most practical model to implement by healthcare workers and facility managers, and also the model most favoured by clients. But the researchers also suggest that a lack of PEPFAR funding for implementation may have contributed to lower uptake of community-based models.
The study found that lack of PEPFAR funding for implementation in for-profit facilities had discouraged these providers from adopting differentiated service delivery models. Although public and private not-for-profit facilities may treat larger numbers of people with HIV at single facilities, for-profit facilities make up more than half of all healthcare providers in Uganda. The researchers say more attention ought to be paid to for-profit providers as countries roll out differentiated service delivery.
Zakumumpa H et al. A mixed-methods evaluation of the uptake of novel differentiated ART delivery models in a national sample of health facilities in Uganda. PLOS ONE, 16: e0254214, 2021.
Full image credit: 'Developing Infrastructure to Promote Quality Health Care'. Baylor College of Medicine Children's Foundation–Malawi / Robbie Flick. USAID images. Available at www.flickr.com/photos/usaid_images/14742507309/in/photolist-osKcNv under a Creative Commons licence CC BY-NC-ND 2.0. Image is for illustrative purposes only.