Investigating the implementation of differentiated HIV services and implications for pregnant and postpartum women: A mixed methods multi-country study

Figures & data

Table 1. Type of facilities surveyed by site.

	South Africa	Malawi	Tanzania
HDSS site name	uMkhanyakude	Karonga	Ifakara
Size of HDSS site (km^2)	438	135	2400
Population of HDSS site	90,000	42,555	169,000
HIV prevalence in the HDSS	35.2%	9.6%	7%
No. of facilities included in the survey	17	5	12
Type of facility
Small clinic/dispensary	16	0	3
Large clinic/small health centre	1	2	0
Large health centre/sub-district hospital	0	3	6
District/referral hospital	0	0	3

Table 2. Summary of differentiated HIV service delivery policies in each country.

	WHO Guidelines	South Africa	Malawi	Tanzania
Who	Trained and supervised lay providers can distribute ART to adults, adolescents and children living with HIV. Trained and supervised community health workers can dispense ART between regular clinic visits^1 For women diagnosed and initiating ART during pregnancy, clinical consultations and ART refills should be integrated into maternal, newborn and child health care where clinical consultations managed by health or lay workers^e ART refills collected by individuals either at facilities or at other distribution points or by groups of clients (in a community ART distribution model)^1	Health facilities need to implement decongestion strategies that ‘reward adherent and stable^a chronic patients’ with a faster service and flexibility to choose their preferred medication collection service’^b^,^c	Only the patient or his registered guardians/treatment supporter is allowed to collect ARVs^6	Facility-based health worker managed groups: clients are seen in age-specific groups managed by a health care worker, e.g. teen clubs, youth clubs^d Family member or treatment supporter refills – clients proposes a family member or treatment supporter to collect their ART refill from the pharmacy^5
When	‘Multi-month prescribing’ whereby depending on the HIV treatment and patient eligibility guidelines in a country, ART patients may receive several months of ART drugs at one time, and will not need to return to health facilities and/or clinics monthly to receive their ARV supply^1 People-centred care offers a patient appointment system and frequency of facility visits	Spaced and fast lane appointments are established as a repeat prescription collection strategy.^4 A minimum of 3 months drug supply and optimised prescription periods to meet the needs of key and vulnerable populations and improve adherence^4	Stable patients receive refills of ART for three or more months instead of one month at a time, so stable patients have a maximum of four clinic visits per year instead of 12. Stable and adherent patients can be given up to 12-week (3-month) appointments^f	ART refills for stable clients should be provided for two months depending on supply^5
Where	Initiation of ART can happen at peripheral health facilities with maintenance at the community level (Community level includes external outreach sites, health posts, home-based services or community-based organisations)^g Through existing outreach services, community-based organisations can provide support for out-of-facility individual models of ART delivery: for example, through regular outreach to hotspots^1 ART refills should be provided as close to people’s homes as possible. Consideration could be given to delinking refill collection from maternal, newborn and child health care^1 Consideration can be given to using lay providers equivalent to mentor mothers for task shifting ART refill distribution^1	Roll-out of innovative approaches to increase treatment uptake and improve treatment outcomes that include male- and adolescent-friendly clinic hours; community- or home-based ART initiation,community facilitated ART refill clubs^3 A centralised dispensing operation that obtains prescriptions for stable chronic patients from health facilities and dispenses a package of medicine for each patient, which they can collect from a health facility (using an express queue) or another convenient pick up point e.g at pharmacies^4	ARVs may not be further distributed outside of certified ART health facilities^6	Facility based Individual fast-track from pharmacy – clients are seen individually within health care facilities and are fast-tracked for collection of the ARVs^5 ART refill should be decentralised to existing facilities including primary health facilities at existing PMTCT sites. Additional dispensaries and health centres should be facilitated to be ART sites dependant on local demand and a clinic access assessment^5 ART refills can be delivered through a mobile outreach strategy by health care worker in hard to reach areas. Clients are seen individually outside of health care facilities by clinical staff as part of routine outreach^5

^a Stable patient: The definition of a stable patient put forward by the World Health Organisation in the 2016 guidelines, states that these are people who have received ART for at least one year and have no adverse drug reactions that require regular monitoring, no current illnesses or pregnancy, are not currently breastfeeding, have good understanding of lifelong adherence and evidence of treatment success (that is two consecutive viral load measurements below 1000 copies/mL and in the absence of viral load monitoring, rising CD4 cell counts or CD4 counts >200 cells/mm³ can be used to indicate treatment success).

^bSouth Africa Department of Health (2016).

^cSouth Africa Department of Health (2017a).

^dMinistry of Health Community Development Gender Elderly and Children (2017).

^eWorld Health Organisation (2017b).

^fMinistry of Health Malawi (2016).

^gWorld Health Organisation (2016).

Table 3. Differentiated care models implemented by site.

		uMkhanyakude		Ifakara		Karonga
		Total	%	Total	%	Total	%
Who	Can ART be collected by other people
	Never	0	0%	0	0%	0	0%
	In exceptional circumstances	1	6%	9	75%	1	20%
	Yes by anyone	0	0%	2	17%	0	0%
	yes but not every visit	3	18%	0	0%	3	60%
	Yes by one designated person	13	76%	1	8%	1	20%
When	Frequency of ART refill visits
	Monthly	10	59%	7	58%	0	0%
	Every 2 months	7	41%	4	33%	2	40%
	Every 3 months	0	0%	1	8%	3	60%
Where	Where can patients get ART refills at the clinic
	Clinic only	15	88%	11	92%	5	100%
	Pharmacy	1	6%	1	8%	0	0%
	HCW managed PLHIV group	3	18%	0	0%	0	0%
	Patient managed PLHIV group	0	0%	0	0%	0	0%
	Where can patients get ART refills in their community
	Not available	10	59%	12	100%	5	100%
	community pharmacy	2	12%	0	0%	0	0%
	pat manage adherence group	3	18%	0	0%	0	0%
	HCW manage adherence group	3	18%	0	0%	0	0%

Table 4. Group participants interviewed per study site.

Sample Groups	South Africa uMkhanyakude	Malawi Karonga	Tanzania Ifakara	Total
PMTCT B+ service users	8	5	8	21
HIV Routine service users	6	7	4	17
PMTCT Lost to follow up	6	5	2	13
Partners	6	0	9	15
Health care workers	7	7	7	21
Refusals	0	0	0	0
Total	33	24	30	87

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