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ORIGINAL ARTICLE
Open Access

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

Amy Huber, Sophie Pascoe, Brooke Nichols, Lawrence Long, Salome Kuchukhidze, Bevis Phiri, Timothy Tchereni and Sydney Rosen
Global Health: Science and Practice June 2021, 9(2):296-307; https://doi.org/10.9745/GHSP-D-20-00532
Amy Huber
aHealth Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa.
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Sophie Pascoe
aHealth Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa.
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Brooke Nichols
aHealth Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa.
bDepartment of Global Health, Boston University School of Public Health, Boston, MA, USA.
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Lawrence Long
aHealth Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa.
bDepartment of Global Health, Boston University School of Public Health, Boston, MA, USA.
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Salome Kuchukhidze
bDepartment of Global Health, Boston University School of Public Health, Boston, MA, USA.
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Bevis Phiri
cClinton Health Access Initiative, Lusaka, Zambia.
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Timothy Tchereni
dClinton Health Access Initiative, Lilongwe, Malawi.
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Sydney Rosen
aHealth Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa.
bDepartment of Global Health, Boston University School of Public Health, Boston, MA, USA.
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  • For correspondence: sbrosen@bu.edu
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    TABLE 1.

    Number of Organization-Modelsa for Differentiated Service Delivery of HIV Treatment Described by Respondents, by Country, Category, and Strategy

    Model CategoryMalawiSouth AfricaZambiaTotal
    Total number of organization-models described264341110
    Number of organization-models per country and category
    Facility-based individual model1361332
    Out-of-facility-based individual model5221643
    Health care worker-led group715426
    Client-led group1089
    Numbers of organization-models per country and strategy
    Adherence clubs011314
    Community adherence groups1087
    Community outreach33411
    External pickup points217626
    Extra clinic hours1124
    Family models2114
    Fast track services2158
    Home delivery0134
    Multimonth dispensing3137
    Nonstable patient models64111
    Key population models1124
    Youth models52310
    • ↵a An organization-model is 1 organization supporting 1 model of care.

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    TABLE 2.

    Twelve Strategies for Differentiated Service Delivery Model for HIV Treatment in Malawi, South Africa, and Zambia, as Reported by Interview Respondents

    Adherence clubsAny group model that is led by a health care worker (professional or lay)
    Community adherence groupsAny group model in which a patient picks up medications for other group members (typically abbreviated CAG)
    Community outreachA variety of models that bring both clinical care and medications into the community, such as nurse-led outreach
    External pickup pointsAny model that delivers antiretroviral medications to pickup points outside clinic facilities, such as lockers, community pharmacies, decentralized pickup points, etc.
    Extra clinic hoursAny model that adds additional hours to a facility's operations to facilitate access, such as on evenings or weekends
    Family modelsAny model designed to serve multiple and/or specific members of a family at once (e.g., pediatric clinic or family clinic)
    Fast track servicesAny model that creates a separate queue, kiosk, or procedure at a facility to speed up service delivery for stable patients
    Home deliveryAny model that delivers antiretroviral medications to patients' homes (e.g., by a community health worker or a bicycle courier)
    Multimonth dispensingAny model in which the primary goal is to dispense medications for a longer duration than is done under standard care (usually 6 months)
    Nonstable patient modelsModels for patients who do not meet definitions of clinical stability, such as high viral load clinics and advanced disease clinics
    Key population modelsModels for a key population such as men who have sex with men or female sex worker
    Youth modelsAny model specifically for youth/teens/adolescents (e.g., teen clubs in Malawi and the scholar model in Zambia)
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    TABLE 3.

    Populations Served by Current Differentiated Service Delivery Models for HIV Treatment and Criteria for Defining Stability, by Country

    Population or RequirementsMalawi, No.South Africa, No.Zambia, No.Total, No.
    Population eligible
    Number of organization-models264341110
    All patients (no restrictions by disease status or age)2103
    Stable and not stable patients
        Adults and adolescents/youth0202
        Adolescents/youth (age restrictions vary)5207
        Children (age restrictions vary)0011
        Total stable and not stable patients54110
    Stable patients only
        All ages001010
        Adults10311455
        Adults and adolescents/youth0099
        Adolescents/youth (age restrictions vary)0033
        Children (age restrictions vary)0101
        Total stable patients only10323678
    Advanced disease/not stable patients only
        All ages4217
        Adults2204
        Children (age restrictions vary)1001
        Total advanced disease/not stable patients74112
    Pregnant/postpartum women only (any disease status)1102
    MSM/FSW (any disease status)1135
    Requirements to be regarded as stable
    Number of organization-models10323678
    ART ≥ 6 months and 1 suppressed viral load54918
    ART ≥ 12 months and 1 suppressed viral load102324
    ART ≥ 12 months and 2 suppressed viral loads026026
    Not specified42410
    • Abbreviations: ART, antiretroviral therapy; FSW, female sex worker; MSM, men who have sex with men.

    • View popup
    TABLE 4.

    Number of Organization-Models for Differentiated Service Delivery of HIV Treatment by Location of Service Delivery and Country

    Location of Service DeliveryNumber of Organization-Models
    Malawi N=26South Africa N=43Zambia N=41Total N=110
    Facility for clinical care with medication pickup at
        Facility1961641
        External pickup point4181537
        Adherence club013114
        Home0134
        Total (facility location for clinical care)23383596
    External location for clinical care
        Clinical care and medications in community33511
        Clinical care and medications at adherence club0202
        Clinical care and medications at home0011
        Total (external location for clinical care)35614
    • View popup
    TABLE 5.

    Frequency of Health Care System Interactions per Year, by Country, Model Category, and Viral Suppression Eligibility Criterion for Differentiated Service Delivery Models for HIV Treatment

    Frequency of Interactions Required per YearMalawiSouth AfricaZambia
    Organization-models, No.Full Clinic Visits,a Median (Range)Other Interactions,b Median (Range)Organization-models, No.Full Clinic Visits,a Median (Range)Other Interactions,b Median (Range)Organization-models, No.Full Clinic Visits,a Median (Range)Other Interactions,b Median (Range)
    Models explicitly for stable patients
    Facility-based individual models
    Every 2 months (6/year)140
    Every 3 months (4/year)22 (2–2)2 (2–2)12482 (2–4)2 (0–2)
    Every 4 months (3/year)32 (2–2)1 (1–1)
    Every 6 months (2/year)32 (2–2)0 (0–0)
    Out-of-facility-based individual models
    Every 2 months (6/year)182 (2–2)4 (4–4)
    Every 3 months (4/year)31 (0–2)4 (2–4)105132 (0–2)2 (2–4)
    Health care worker-led group models
    Every 2 months (6/year)102 (2–2)4 (4–4)
    Every 3 months (4/year)12242 (2–4)2 (0–2)
    Every 6 months (2/year)102
    Client-led group models
    Every 1 month (12/year)1210
    Every 3 months (4/year)12262 (2–2)2 (2–2)
    Every 6 months (2/year)111
    Models not requiring stabilityc
    Facility-based individual models
    Every 1 month (12/year)60 (0–0)12 (12–12)20 (0–0)12 (12–12)20 (0–0)12 (12–12)
    Every 2 months (6/year)20 (0-0)6 (6–6)
    Every 3 months (4/year)104
    Visits aligned to PMTCT schedule153
    Out-of-facility-based individual models
    Every 2 months (6/year)30 (0–0)6 (6–6)
    Every 3 months (4/year)20 (0–0)4 (4–4)32 (2–2)2 (2–2)
    Health care worker-led group models
    Every 1 month (12/year)20 (0–0)12 (12–12)30 (0–2)12 (10–12)
    Every 2 months (6/year)20 (0–0)6 (6–6)
    Visits aligned to child vaccine schedule108
    Not specified2
    • ↵a A full clinic visit is a conventional facility visit that provides the services that were typical of a predifferentiation visit, generally including a consultation with a clinician, counseling, laboratory tests if scheduled, and a medication refill.

    • ↵b Other interactions include any interaction with a provider that has been tailored for the population served, including off-site medication pickups, adherence club participation, or a clinical consultation adjusted for the population in question, including specialist consultations for certain types of patients (i.e., all interactions except conventional, undifferentiated full clinic visits).

    • ↵c Includes models for known unsuppressed patients, high viral load clinics, pediatric clinics, and models that accept both stable and nonstable patients.

    • View popup
    TABLE 6.

    Months of Antiretrovirals Dispensed in Differentiated Service Delivery Models for HIV Treatment

    Average Months of Antiretrovirals Dispensed in ModelNumber of Organization-Models
    Malawi (N=26)South Africa (N=43)Zambia (N=21)Total (N=110)
    1 month75315
    2 months234036
    3 months711220
    1 or 3 months (patients typically start with 1 month, then move to 3 months)2226
    6 months31711
    3 or 6 months (typically previously dispensed 3 months but transitioning to 6 months in line with national policy)301720
    Not reported2002
    • View popup
    TABLE 7.

    Different Cadres of Clinical Care Providers and Antiretroviral Therapy Dispensers Employed in Differentiated Service Delivery Models for HIV Treatment in Malawi, South Africa, and Zambia

    ProviderNumber of Organizational-Models
    Facility-based IndividualOut-of-facility-based IndividualHealth Care Worker-led GroupClient-led GroupTotal
    Clinical care provider
        Medical doctor/medical officer/clinical officer912214
        Nurse72816051
        Community health worker01012
        Non-specified clinician373215
        Unclear/not reported1365428
    Antiretroviral therapy dispenser
        Pharmacist/pharmacy assistant1272021
        Nurse/clinician773017
        Community health worker065011
        Designated patient021912
        Lay counselor/trained non-clinical personnel0149023
        Medication locker/remote pharmacist03003
        Unclear/not reported1346023

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Global Health: Science and Practice: 9 (2)
Global Health: Science and Practice
Vol. 9, No. 2
June 30, 2021
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Differentiated Service Delivery Models for HIV Treatment in Malawi, South Africa, and Zambia: A Landscape Analysis
Amy Huber, Sophie Pascoe, Brooke Nichols, Lawrence Long, Salome Kuchukhidze, Bevis Phiri, Timothy Tchereni, Sydney Rosen
Global Health: Science and Practice Jun 2021, 9 (2) 296-307; DOI: 10.9745/GHSP-D-20-00532

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Differentiated Service Delivery Models for HIV Treatment in Malawi, South Africa, and Zambia: A Landscape Analysis
Amy Huber, Sophie Pascoe, Brooke Nichols, Lawrence Long, Salome Kuchukhidze, Bevis Phiri, Timothy Tchereni, Sydney Rosen
Global Health: Science and Practice Jun 2021, 9 (2) 296-307; DOI: 10.9745/GHSP-D-20-00532
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