scholarly journals 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

2021 ◽  
Vol 5 ◽  
pp. 177
Author(s):  
Sydney Rosen ◽  
Brooke Nichols ◽  
Teresa Guthrie ◽  
Mariet Benade ◽  
Salome Kuchukhidze ◽  
...  
Keyword(s):  
Observational Study ◽  
Service Delivery ◽  
Field Studies ◽  
Conventional Care ◽  
Hiv Treatment ◽  
Sub Saharan Africa ◽  
Differentiated Service ◽  
African Countries ◽  
Sub Saharan ◽  
Cluster Randomized

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.

scholarly journals Retention in Care and Viral Suppression in Differentiated Service Delivery Models for HIV Treatment in Sub-Saharan Africa: A Rapid Systematic Review

2020 ◽  
Author(s):  
Lawrence Long ◽  
Salome Kuchukhidze ◽  
Sophie Pascoe ◽  
Brooke E. Nichols ◽  
Matthew P. Fox ◽  
...  
Keyword(s):  
Systematic Review ◽  
Service Delivery ◽  
Clinical Outcomes ◽  
Viral Suppression ◽  
Retention In Care ◽  
Conventional Care ◽  
Hiv Treatment ◽  
Sub Saharan Africa ◽  
Differentiated Service ◽  
Sub Saharan

Introduction: Differentiated service delivery (DSD) models for antiretroviral treatment (ART) for HIV are being scaled up in the expectation that they will improve the quality and efficiency of treatment delivery and reduce costs while maintaining at least equivalent clinical outcomes. Even this minimum requirement of equivalent clinical outcomes is poorly documented for most models and settings, however. We reviewed the recent literature on DSD models to describe what is known about clinical outcomes. Methods: We conducted a rapid systematic review of peer-reviewed publications in PubMed, Embase, and the Web of Science and major international conference abstracts that reported outcomes of DSD models for the provision of ART in sub-Saharan Africa from January 1, 2016 to September 12, 2019. Sources reporting standard clinical HIV treatment metrics, primarily retention in care and viral load suppression, were reviewed and categorized by DSD model and source quality assessed. Results and Discussion: Twenty-nine papers and abstracts describing 37 DSD models and reporting 52 discrete outcomes met search inclusion criteria. Of the 37 models, 7 (19%) were facility-based individual models, 12 (32%) out-of-facility based individual models, 5 (14%) client-led groups, and 13 (35%) healthcare worker-led groups. Retention was reported for 73% of the models and viral suppression for 57%. Where a comparison with conventional care was provided, retention in most DSD models was within 5% of that for conventional care; where no comparison was provided, retention generally exceeded 80%. For viral suppression, all those with a comparison to conventional care reported a small increase in suppression in the DSD model; reported suppression exceeded 90% in 11/21 models. Analysis was limited by the extensive heterogeneity of study designs, outcomes, models, and populations. Most sources did not provide comparisons with conventional care, and metrics for assessing outcomes varied widely and were in many cases poorly defined. Conclusion: Existing evidence on the clinical outcomes of DSD models for HIV treatment in sub-Saharan Africa is limited in both quantity and quality but suggests that retention in care and viral suppression are roughly equivalent to those in conventional models of care.

scholarly journals Evaluating the sustainability of differentiated service delivery interventions for stable ART clients in sub-Saharan Africa: a systematic review protocol

BMJ Open ◽  
2020 ◽  
Vol 10 (1) ◽  
pp. e033156
Author(s):  
Nwanneka Ebelechukwu Okere ◽  
Lisa Urlings ◽  
Denise Naniche ◽  
Tobias F Rinke de Wit ◽  
Gabriela B Gomez ◽  
...  
Keyword(s):  
Service Delivery ◽  
Low Income ◽  
English Literature ◽  
Sub Saharan Africa ◽  
People Living With Hiv ◽  
Differentiated Service ◽  
Middle Income ◽  
Ethical Approval ◽  
Quantitative Synthesis ◽  
Sub Saharan

IntroductionIn 2015, WHO recommended immediate treatment for people living with HIV (PLHIV). As a result, the number of PLHIV needing antiretroviral therapy (ART) in sub-Saharan Africa (SSA) doubled from 12 million to over 25 million. This put a strain on already weak health systems and inspired the exploration of innovative service delivery models—differentiated service delivery (DSD). In DSD, services are tailored according to client clinical type and offer much-needed improvement in efficiency. The potential of achieving good outcomes for both clients and the health system plus the promise of sustainability motivates DSD promotion especially in low-income and middle-income countries. This review aims to evaluate the sustainability of DSD interventions.Methods and analysisWe will systematically review peer-reviewed English literature published between 2000 and 2019 identified by searching PubMed and EMBASE databases. Main inclusion criteria comprise studies describing DSD interventions conducted in SSA focused on stable adult ART clients, whether described alone or compared with clinic-based service delivery. Quality of included studies will be assessed employing the Down and Black’s and Joanne Briggs Institute checklists for quantitative and qualitative studies, respectively. We will apply a comprehensive sustainability framework including 40 individual constructs to evaluate, score and rank each intervention for sustainability. Narrative and quantitative synthesis will be conducted as appropriate.Ethics and disseminationNo ethical approval is required for this study as it is a review of published or publicly available data. Review results will be published in a peer-reviewed journal and presented at international conferences.PROSPERO registration numberCRD42019120891.

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 Implementation of differentiated service delivery for paediatric HIV care and treatment: opportunities, challenges and experience from seven sub-Saharan African countries

2020 ◽  
Vol 8 (3) ◽  
pp. e000393
Author(s):  
Rebecca Abelman ◽  
Catharina Alons ◽  
Jeni Stockman ◽  
Ivan Teri ◽  
Anna Grimsrud ◽  
...  
Keyword(s):  
Service Delivery ◽  
Children And Adolescents ◽  
Care Delivery ◽  
Hiv Care ◽  
Differentiated Service ◽  
Viral Load Suppression ◽  
African Countries ◽  
Care And Treatment ◽  
Sub Saharan ◽  
Living With Hiv

Differentiated service delivery (DSD) models for HIV often exclude children and adolescents. Given that children and adolescents have lower rates of HIV diagnosis, treatment and viral load suppression, there is a need to use DSD to meet the needs of children and adolescents living with HIV. This commentary reviews the concept of DSD, examines the application of DSD to the care of children and adolescents living with HIV, and describes national guidance on use of DSD for children and adolescents and implementation of DSD for HIV care and treatment in children and adolescents in Elizabeth Glaser Pediatric AIDS Foundation (EGPAF)–supported programmes in seven sub-Saharan countries between 2017 and 2019. Programme descriptions include eligibility criteria, location and frequency of care delivery, healthcare cadre delivering the care, as well as the number of EGPAF-supported facilities supporting each type of DSD model. A range of DSD models were identified. While facility-based models predominate, several countries support community-based models. Despite significant uptake of various DSD models for children and adolescents, there was variable coverage within countries and variability in age criteria for each model. While the recent uptake of DSD models for children and adolescents suggests feasibility, more can be done to optimise and extend the use of DSD models for children and adolescents living with HIV. Barriers to further DSD uptake are described and solutions proposed. DSD models for children and adolescents are a critical tool that can be optimised to improve the quality of HIV care and outcomes for children and adolescents.

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 Leveraging differentiated HIV service delivery to expand tuberculosis preventive treatment: a call to action

2020 ◽  
Vol 24 (2) ◽  
pp. 165-169
Author(s):  
M. Rabkin ◽  
A. A. Howard ◽  
P. Ehrenkranz ◽  
L. G. Fernandez ◽  
P. Preko ◽  
...  
Keyword(s):  
Service Delivery ◽  
Linkage To Care ◽  
Preventive Treatment ◽  
Hiv Treatment ◽  
Sub Saharan Africa ◽  
Treatment Delivery ◽  
Call To Action ◽  
Heavy Burden ◽  
Sub Saharan ◽  
High Level

Tuberculosis (TB) is the leading cause of death among people living with human immunodeficiency virus (PLHIV), and sub-Saharan Africa has a particularly heavy burden of HIV-associated TB. Although effective TB preventive treatment (TPT) has been available for decades and shorter regimens are newly available in some settings, TPT coverage among PLHIV is suboptimal, leading to preventable illness and death. In 2018, the United Nations High-Level Meeting on Ending Tuberculosis called for ambitious new targets for TPT coverage among PLHIV and many countries in sub-Saharan Africa have redoubled their efforts to take TPT to scale. Importantly, however, this push to expand TPT among PLHIV is taking place in the context of a changing HIV treatment delivery landscape. Countries in sub-Saharan Africa are at the forefront of innovative changes in HIV program design, including a shift towards less-intensive differentiated service delivery (DSD) models for stable patients doing well on antiretroviral therapy. Understanding the opportunities and challenges that DSD presents for TB diagnosis, prevention and linkage to care among PLHIV will be critical to success.

scholarly journals Fertility transition in selected sub-Saharan African countries: the role of family planning programs

F1000Research ◽  
2020 ◽  
Vol 8 ◽  
pp. 1748
Author(s):  
Vincent Otieno ◽  
Alfred Agwanda ◽  
Anne Khasakhala
Keyword(s):  
Family Planning ◽  
Service Delivery ◽  
Fertility Transition ◽  
Reproductive Age ◽  
Sub Saharan Africa ◽  
African Countries ◽  
Fertility Preferences ◽  
Fertility Preference ◽  
Current Fertility ◽  
Sub Saharan

Background: Change in fertility rate across societies is a complex process that involves changes in the demand for children, the diffusion of new attitudes about family planning and greater accessibility to contraception. Scholars have concentrated on a range of factors associated with fertility majorly at the national scale. However, considerably less attention has been paid to fertility preference - a pathway through which various variables act on fertility. It is understood that women have inherent fertility preferences which each they seek to achieve over her reproductive cycle. However, the service delivery enhancement levels and capacity across countries as integral pathways to this goal accomplishment stand on their way towards eventual outcomes. Precisely, the Sub-Saharan African countries’ disparities amid similarities in their population policies is a cause of concern. Methods: Using Bongaarts reformulation of Easterlin conceptual scheme of 1985 on DHS data, the understanding of the current fertility transition in general would provide explanations to the observed fertility dynamics. This study therefore is an attempt to explain the current fertility transition through women’s fertility preference. Results: Results reveal that fertility transition is diverse across sub-Saharan Africa; generally, on a decline course in most of the countries. The huge disparities in fertility preferences among women of reproductive age and its non-significant change in the implementation indices points at the service delivery performance underneath regarding the proportion of demand to family planning commodities satisfied. Service delivery indicators are integral to fertility preference achievement within households as well as a country’s overall positioning regarding fertility transition at the macroscale. Conclusions: It is therefore plausible to conclude that the improvement of service delivery in general; precisely touching on the availability and the uptake of quality birth control technologies is one of the most feasible means through which countries can fast track their fertility transitions.

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.

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