scholarly journals Acceptability of Community-Based Tuberculosis Preventive Treatment for People Living with HIV in Zimbabwe

Healthcare ◽  
2022 ◽  
Vol 10 (1) ◽  
pp. 116
Author(s):  
Martin K. Msukwa ◽  
Munyaradzi P. Mapingure ◽  
Jennifer M. Zech ◽  
Tsitsi B. Masvawure ◽  
Joanne E. Mantell ◽  
...  
Keyword(s):  
Service Delivery ◽  
Preventive Treatment ◽  
Hiv Treatment ◽  
People Living With Hiv ◽  
Differentiated Service ◽  
Community Based ◽  
Time Motion ◽  
Symptom Screening ◽  
Adherence Monitoring ◽  
Living With Hiv

As Zimbabwe expands tuberculosis preventive treatment (TPT) for people living with HIV (PLHIV), the Ministry of Health and Child Care is considering making TPT more accessible to PLHIV via less-intensive differentiated service delivery models such as Community ART Refill Groups (CARGs). We designed a study to assess the feasibility and acceptability of integrating TPT into CARGs among key stakeholders, including CARG members, in Zimbabwe. We conducted 45 key informant interviews (KII) with policy makers, implementers, and CARG leaders; 16 focus group discussions (FGD) with 136 PLHIV in CARGs; and structured observations of 8 CARG meetings. KII and FGD were conducted in English and Shona. CARG observations were conducted using a structured checklist and time-motion data capture. Ninety six percent of participants supported TPT integration into CARGs and preferred multi-month TPT dispensing aligned with ART dispensing schedules. Participants noted that the existing CARG support systems could be used for TB symptom screening and TPT adherence monitoring/support. Other perceived advantages included convenience for PLHIV and decreased health facility provider workloads. Participants expressed concerns about possible medication stockouts and limited knowledge about TPT among CARG leaders but were confident that CARGs could effectively provide community-based TPT education, adherence monitoring/support, and TB symptom screening provided that CARG leaders received appropriate training and supervision. These results are consistent with findings from pilot projects in other African countries that are scaling up both differentiated service delivery for HIV and TPT and suggest that designing contextually appropriate approaches to integrating TPT into less-intensive HIV treatment models is an effective way to reach people who are established on ART but who may have missed out on access to TPT.

scholarly journals Comparing Patients’ Experiences in Three Differentiated Service Delivery Models for HIV Treatment in South Africa

2021 ◽  
pp. 104973232110503
Author(s):  
Ferdinand C. Mukumbang ◽  
Sibusiso Ndlovu ◽  
Brian van Wyk
Keyword(s):  
Service Delivery ◽  
Hiv Treatment ◽  
Self Management ◽  
People Living With Hiv ◽  
Service Delivery Model ◽  
Differentiated Service ◽  
Descriptive Phenomenology ◽  
Service Delivery Models ◽  
Living With Hiv ◽  
Delivery Models

Differentiated service delivery for HIV treatment seeks to enhance medication adherence while respecting the preferences of people living with HIV. Nevertheless, patients’ experiences of using these differentiated service delivery models or approaches have not been qualitatively compared. Underpinned by the tenets of descriptive phenomenology, we explored and compared the experiences of patients in three differentiated service delivery models using the National Health Services’ Patient Experience Framework. Data were collected from 68 purposively selected people living with HIV receiving care in facility adherence clubs, community adherence clubs, and quick pharmacy pick-up. Using the constant comparative thematic analysis approach, we compared themes identified across the different participant groups. Compared to facility adherence clubs and community adherence clubs, patients in the quick pharmacy pick-up model experienced less information sharing; communication and education; and emotional/psychological support. Patients’ positive experience with a differentiated service delivery model is based on how well the model fits into their HIV disease self-management goals.

scholarly journals Economic evaluation of a cluster randomized, non-inferiority trial of differentiated service delivery models of HIV treatment in Zimbabwe

2021 ◽  
Author(s):  
Mariet Benade ◽  
Brooke E Nichols ◽  
Geoffrey Fatti ◽  
Salome Kuchukhidze ◽  
Kudakwashe Takarinda ◽  
...  
Keyword(s):  
Viral Load ◽  
Service Delivery ◽  
Annual Cost ◽  
Hiv Treatment ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Differentiated Service ◽  
Community Based ◽  
Cluster Randomized ◽  
Delivery Models

Background: About 85% of Zimbabwe's >1.4 million people living with HIV are on antiretroviral treatment (ART). Further expansion of its treatment program will require more efficient use of existing resources. Two promising strategies for reducing resource utilization per patient are multi-month medication dispensing and community-based service delivery. We evaluated the costs to providers and patients of community-based, multi-month ART delivery models in Zimbabwe. Methods:We used resource and outcome data from a cluster-randomized non-inferiority trial of three differentiated service delivery (DSD) models targeted to patients stable on ART: 3-month facility-based care (3MF), community ART refill groups (CAGs) with 3-month dispensing (3MC), and CAGs with 6-month dispensing (6MC). Using local unit costs, we estimated the annual cost in 2020 USD of providing HIV treatment per patient from the provider and patient perspectives. Results:In the trial, retention at 12 months was 93.0% in the 3MF, 94.8% in the 3MC, and 95.5% in the 6MC arms. The total average annual cost of HIV treatment per patient was $187 (standard deviation $39), $178 ($30), and $167 ($39) in each of the three arms, respectively. The annual cost/patient was dominated by ART medications (79% in 3MF, 87% in 3MC; 92% in 6MC), followed by facility visits (12%, 5%, 5%, respectively) and viral load (8%, 8%, 2%, respectively). When costs were stratified by district, DSD models cost slightly less, with 6MC the least expensive in all districts. Savings were driven by differences in the number of facility visits made/year, as expected, and low uptake of annual viral load tests in the 6-month arm. The total annual cost to patients to obtain HIV care was $10.03 ($2) in the 3MF arm, $5.12 ($0.41) in the 3MC arm, and $4.40 ($0.39) in the 6MF arm. Conclusions:For stable ART patients in Zimbabwe, 3- and 6-month community-based multi-month dispensing models cost less for both providers and patients than 3-month facility-based care and had non-inferior outcomes.

scholarly journals Reducing time to differentiated service delivery for newly diagnosed people living with HIV in Kigali, Rwanda: study protocol for a pilot, unblinded, randomised controlled study

BMJ Open ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. e047443
Author(s):  
Jonathan Ross ◽  
Gad Murenzi ◽  
Sarah Hill ◽  
Eric Remera ◽  
Charles Ingabire ◽  
...  
Keyword(s):  
Service Delivery ◽  
Health Centre ◽  
Albert Einstein College ◽  
Secondary Outcome ◽  
Controlled Study ◽  
People Living With Hiv ◽  
Newly Diagnosed ◽  
Differentiated Service ◽  
Viral Loads ◽  
Living With Hiv

IntroductionCurrent HIV guidelines recommend differentiated service delivery (DSD) models that allow for fewer health centre visits for clinically stable people living with HIV (PLHIV). Newly diagnosed PLHIV may require more intensive care early in their treatment course, yet frequent appointments can be burdensome to patients and health systems. Determining the optimal parameters for defining clinical stability and transitioning to less frequent appointments could decrease patient burden and health system costs. The objectives of this pilot study are to explore the feasibility and acceptability of (1) reducing the time to DSD from 12 to 6 months after antiretroviral therapy (ART) initiation,and (2) reducing the number of suppressed viral loads required to enter DSD from two to one.Methods and analysesThe present study is a pilot, unblinded trial taking place in three health facilities in Kigali, Rwanda. Current Rwandan guidelines require PLHIV to be on ART for ≥12 months with two consecutive suppressed viral loads in order to transition to less frequent appointments. We will randomise 90 participants to one of three arms: entry into DSD at 6 months after one suppressed viral load (n=30), entry into DSD at 6 months after two suppressed viral loads (n=30) or current standard of care (n=30). We will measure feasibility and acceptability of this intervention; clinical outcomes include viral suppression at 12 months (primary outcome) and appointment attendance (secondary outcome).Ethics and disseminationThis clinical trial was approved by the institutional review board of Albert Einstein College of Medicine and by the Rwanda National Ethics Committee. Findings will be disseminated through conferences and peer-reviewed publications, as well as meetings with stakeholders.Trial registration numberNCT04567693.

scholarly journals Implementing TB preventive treatment within differentiated HIV service delivery models in global programs

2020 ◽  
Vol 10 (3) ◽  
pp. 104-110
Author(s):  
A. T. Boyd ◽  
B. Moore ◽  
M. Shah ◽  
C. Tran ◽  
H. Kirking ◽  
...  
Keyword(s):  
Service Delivery ◽  
Care Delivery ◽  
Scale Up ◽  
Preventive Treatment ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Emergency Plan ◽  
The Us ◽  
Living With Hiv ◽  
Delivery Models

Global HIV program stakeholders, including the US President’s Emergency Plan for AIDS Relief (PEPFAR), are undertaking efforts to ensure that eligible people living with HIV (PLHIV) receiving antiretroviral treatment (ART) receive a course of TB preventive treatment (TPT). In PEPFAR programming, this effort may require providing TPT not only to newly diagnosed PLHIV as part of HIV care initiation, but also to treatment-experienced PLHIV stable on ART who may not have been previously offered TPT. TPT scale-up is occurring at the same time as a trend to provide more person-centered HIV care through differentiated service delivery (DSD). In DSD, PLHIV stable on ART may receive less frequent clinical follow-up or receive care outside the traditional clinic-based model. The misalignment between traditional delivery of TPT and care delivery in innovative DSD may require adaptations to TPT delivery practices for PLHIV. Adaptations include components of planning and operationalization of TPT in DSD, such as determination of TPT eligibility and TPT initiation, and clinical management of PLHIV while on TPT. A key adaptation is alignment of timing and location for TPT and ART prescribing, monitoring, and dispensing. Conceptual examples of TPT delivery in DSD may help program managers operationalize TPT in HIV care.

scholarly journals Expansion of a National Differentiated Service Delivery Model Increases Access to Treatment for HIV and Other Chronic Conditions in South Africa

2021 ◽  
Author(s):  
Lingrui Liu ◽  
Sarah Christie ◽  
Maggie Munsamy ◽  
Phil Roberts ◽  
Merlin Pillay ◽  
...  
Keyword(s):  
South Africa ◽  
Service Delivery ◽  
Noncommunicable Diseases ◽  
People Living With Hiv ◽  
Service Delivery Model ◽  
Differentiated Service ◽  
National Scale ◽  
Access To Treatment ◽  
Delivery Model ◽  
Living With Hiv

Abstract Background: South Africa is home to 7.7 million people living with HIV and supports the largest antiretroviral therapy (ART) program worldwide. Despite global investment in HIV service delivery and the parallel threat of non-communicable diseases (NCDs), there are few examples of integrated programs addressing both HIV and NCDs through differentiated service delivery. In 2014, the National Department of Health (NDoH) launched the Central Chronic Medicines Dispensing and Distribution (CCMDD) program to provide patients with chronic disease, including HIV, with differentiated access to medications via community-based pick-up points. This study describes the expansion of CCMDD to national scale.Methods: Yale monitors CCMDD enrollment as part of its mixed methods evaluation of Project Last Mile (PLM), a national technical support partner for CCMDD since 2016. From March 2016 through October 2019, cumulative weekly data on CCMDD uptake [patients enrolled, facilities registered, pick-up points contracted], type of medication collected [ART only; NCD only; and ART-NCD] and of collection site used [external pick-up points; adherence/outreach clubs; or facility-based fast lanes], were extracted for descriptive, longitudinal analysis.Results: As of October 2019, 3,436 health facilities were registered with CCMDD across 46 health districts (88% national coverage), and 2,037 external pick-up points had been established. A total of 2,069,039 patients were active on CCMDD, a significant increase since 2018 (p<0.001), including 76% collecting ART [64% ART only, 12% ART plus NCD/comorbidities] and 479,120 [24%] collecting for chronic diseases only. Further, 734,005 (35%) of patients were collecting from external pick-up points, a 73% increase in patient volume from 2018.Discussion: This longitudinal description of CCMDD provides an example of a path to national scale for a differentiated service delivery model that integrates management of HIV and noncommunicable diseases. This study demonstrates the success of the program in engaging patients who are not living with HIV, which bodes well for the potential of the program to address the rising burden of NCDs in South Africa.Conclusion: The results signal potential for expansion in resource-limited settings, particularly in the context of private sector strategic support.

scholarly journals Similar costs and outcomes for differentiated service delivery models for HIV treatment in Uganda

2021 ◽  
Author(s):  
Teresa Guthrie ◽  
Charlotte Muheki ◽  
Sydney Rosen ◽  
Shiba Kanoowe ◽  
Stephen Lagony ◽  
...  
Keyword(s):  
Service Delivery ◽  
Viral Suppression ◽  
Standard Of Care ◽  
Hiv Treatment ◽  
Sub Saharan Africa ◽  
Total Annual Cost ◽  
Differentiated Service ◽  
Community Based ◽  
Service Delivery Models ◽  
Delivery Models

Background: Like many countries in sub-Saharan Africa, Uganda has scaled up differentiated service delivery models (DSDMs) for HIV treatment, but little information is available about the relative costs of the models. We estimated the total annual cost per patient and total cost per patient virally suppressed in five DSDMs, including facility- and community-based models and the standard of care. Methods: We conducted a cost/outcome study from the perspective of the service provider, using retrospective patient record review of a cohort of patients over a two-year period, with bottom-up collection of patient resource utilization data, top-down collection of above-delivery level and delivery-level provider fixed operational costs, and local unit costs. We enrolled adults on ART (>18 years old) enrolled in 47 DSDMs located at facilities or community-based service points in four regions of Uganda with at least 24 months of follow-up data. DSDMs assessed included facility-based groups (FBG); fast-track drug refills (FDR); community client-led ART delivery (CCLAD); community drug distribution points (CDDP); and facility-based individual management (FBIM), which is the standard of care model for new, complex, and virally unsuppressed patients. Viral suppression was defined as <1000 copies/ml. Results: Retention in care was 98% for the sample as a whole [96-100%]. Over viral suppression was 91%, which varied from 86% among patients in FBIM (with the largest share of complex / virally unsuppressed patients) to 93% among CDDP patients. The mean cost to the provider (Ministry of Health or NGO implementers) was $152 per annum per patient treated, ranging from $141 for FBG to $166 for FDR. Differences among the costs of the models were largely due to ARV regimens and proportions of patients on second line regimens. Service delivery costs, excluding ARVs, other medicines and laboratory tests, were modest, ranging from $9.66-16.43 per patient. Conclusions: Differentiated ART service delivery in Uganda achieved excellent treatment outcomes at a cost similar to the standard of care (FBIM). While large budgetary savings might not be immediately realized, the reallocation of saved staff time could improve health system efficiency as facilities and patients gain more experience with DSD models.

scholarly journals HIV Treatment in sub-Saharan Africa: Did bureaucratic headwinds delay access to dolutegravir?

2019 ◽  
Author(s):  
Reuben Granich ◽  
Somya Gupta
Keyword(s):  
Service Delivery ◽  
National Level ◽  
Essential Element ◽  
Hiv Treatment ◽  
Sub Saharan Africa ◽  
World Health ◽  
Critical Element ◽  
People Living With Hiv ◽  
Sub Saharan ◽  
Living With Hiv

IntroductionThe World Health Organization now recommends dolutegravir (DTG) as part of the preferred first-line treatment for all adults living with HIV including women who may become pregnant. The new regimen with its high barrier to resistance, shortened time to suppression, superior side effects profile, and lower health sector and individual costs, represents a significant improvement. The recommendation removes an important obstacle to accessing dolutegravir as an essential element in controlling the epidemic. DiscussionTranslating science to policy to HIV service delivery is complex and vulnerable to significant delays. WHO, assuming a regulatory role, used preliminary Botswana Tsepamo study information regarding neural tube defects to issue a “safety signal” regarding DTG in May 2018. Regulatory evaluations of rare adverse reactions are complex, take time, and require considerable subject area specific expertise. After over a year, the WHO reversed its initial findings and issued revised treatment recommendations. However, the mixed messaging and confusion around dolutegravir’s safety profile has delayed national level adoption. The pace of national adoption of new WHO recommendations is measurable through published national guidelines and/or circulars available in the public domain. After 2015, published guidelines for 22 of 46 sub-Saharan countries (94% of 2018 regional HIV burden) showed that only three countries representing 4% of regional burden have adopted the new WHO preferred 1st line recommendations. ConclusionsMonitoring and evaluating the translation of science to service delivery is a critical element of successful disease control and elimination. The DTG false alarm and ongoing delayed access provides an opportunity to learn valuable lessons and implement corrective actions. However, lessons can only be learned by accurately describing and examining the timeline, processes, and impact of policy decisions that can adversely impact millions of people living with HIV. As with any successful global disease elimination effort or major project, it is important to establish a critical pathway for translation of science to service delivery and hold people and agencies accountable for their roles in accelerating and/or delaying progress.

scholarly journals Title: Expansion of a national differentiated service delivery model to support people living with HIV and other chronic conditions in South Africa: a descriptive analysis

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Lingrui Liu ◽  
Sarah Christie ◽  
Maggie Munsamy ◽  
Phil Roberts ◽  
Merlin Pillay ◽  
...  
Keyword(s):  
South Africa ◽  
Service Delivery ◽  
Chronic Diseases ◽  
Descriptive Analysis ◽  
Noncommunicable Diseases ◽  
People Living With Hiv ◽  
Service Delivery Model ◽  
Differentiated Service ◽  
Delivery Model ◽  
Living With Hiv

Abstract Background South Africa is home to 7.7 million people living with HIV and supports the largest antiretroviral therapy (ART) program worldwide. Despite global investment in HIV service delivery and the parallel challenge of non-communicable diseases (NCDs), there are few examples of integrated programs addressing both HIV and NCDs through differentiated service delivery. In 2014, the National Department of Health (NDoH) of South Africa launched the Central Chronic Medicines Dispensing and Distribution (CCMDD) program to provide patients who have chronic diseases, including HIV, with alternative access to medications via community-based pick-up points. This study describes the expansion of CCMDD toward national scale. Methods Yale monitors CCMDD expansion as part of its mixed methods evaluation of Project Last Mile, a national technical support partner for CCMDD since 2016. From March 2016 through October 2019, cumulative weekly data on CCMDD uptake [patients enrolled, facilities registered, pick-up points contracted], type of medication provided [ART only; NCD only; and ART-NCD] and collection sites preferred by patients [external pick-up points; adherence/outreach clubs; or facility-based fast lanes], were extracted for descriptive, longitudinal analysis. Results As of October 2019, 3,436 health facilities were registered with CCMDD across 46 health districts (88 % of South Africa’s districts), and 2,037 external pick-up points had been contracted by the NDoH. A total of 2,069,039 patients were actively serviced through CCMDD, a significant increase since 2018 (p < 0.001), including 76 % collecting ART [64 % ART only, 12 % ART plus NCD/comorbidities] and 479,120 [24 %] collecting medications for chronic diseases only. Further, 734,005 (35 %) of patients were collecting from contracted, external pick-up points, a 73 % increase in patient volume from 2018. Discussion This longitudinal description of CCMDD provides an example of growth of a national differentiated service delivery model that integrates management of HIV and noncommunicable diseases. This study demonstrates the success of the program in engaging patients irrespective of their chronic condition, which bodes well for the potential of the program to address the rising burden of both HIV and NCDs in South Africa. Conclusions The CCMDD program expansion signals the potential for a differentiated service delivery strategy in resource-limited settings that can be agnostic of the patients chronic disease condition.

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