Personal preferences should drive the scale up of differentiated antiretroviral therapy models
Offered a choice of different types of HIV treatment services, people with clinically stable HIV in urban Zimbabwe expressed strong preferences for respectful healthcare providers, services delivered in healthcare facilities and receiving care as an individual, according to a study published in January in PLOS ONE. Differentiated service delivery models that involved groups or community settings were not favoured. Lower costs, less frequent visits and shorter wait times were also preferred.
Differentiated service delivery models simplify and adapt HIV services to reflect the needs of various groups of people living with HIV while reducing unnecessary burden on the health system. The models may vary service location (health facility or community based), visit frequency, individual or group appointment, and so on. Differentiated service delivery models have been shown to increase retention, improve service quality and programme outcomes, reduce time and costs to people living with HIV, and are more sustainable for lifelong HIV care.
As little is known about preferences of people living with HIV regarding differentiated service delivery, Dr Miriam Rabkin and colleagues conducted a mixed methods study in Harare, the capital city of Zimbabwe.
In Zimbabwe, people living with HIV who are stable on antiretroviral therapy can opt-in for one of five options for differentiated service delivery. Those eligible for differentiated service delivery are over 18 years, stable on their current antiretroviral therapy regimen for at least six months, do not have an opportunistic infection or acute illness, and have an undetectable viral load (or, where viral load testing is not available, a CD4 count over 200).
The five differentiated service delivery models were introduced in 2017 by the Ministry of Health, with the goal of enrolling 65% of eligible people in one of the five models by the end of 2019. By 2018, 35% of eligible people living with HIV were enrolled in one of them.
All the models involved quarterly visits or meetings, with an annual clinical examination and laboratory testing in a health facility. These five models are as follows:
Differentiated service delivery models simplify and adapt HIV services to reflect the needs of various groups of people living with HIV while reducing unnecessary burden on the health system. The models may vary service location (health facility or community based), visit frequency, individual or group appointment, and so on. Differentiated service delivery models have been shown to increase retention, improve service quality and programme outcomes, reduce time and costs to people living with HIV, and are more sustainable for lifelong HIV care.
As little is known about preferences of people living with HIV regarding differentiated service delivery, Dr Miriam Rabkin and colleagues conducted a mixed methods study in Harare, the capital city of Zimbabwe.
In Zimbabwe, people living with HIV who are stable on antiretroviral therapy can opt-in for one of five options for differentiated service delivery. Those eligible for differentiated service delivery are over 18 years, stable on their current antiretroviral therapy regimen for at least six months, do not have an opportunistic infection or acute illness, and have an undetectable viral load (or, where viral load testing is not available, a CD4 count over 200).
The five differentiated service delivery models were introduced in 2017 by the Ministry of Health, with the goal of enrolling 65% of eligible people in one of the five models by the end of 2019. By 2018, 35% of eligible people living with HIV were enrolled in one of them.
All the models involved quarterly visits or meetings, with an annual clinical examination and laboratory testing in a health facility. These five models are as follows:
- Fast track refills, a health facility-based individual model, where people get their medication from the pharmacy or dispensing point.
- Community antiretroviral therapy refill groups of 6-12 people, where one member goes to the health facility every three months to collect medications for all.
- Club refills, a health facility-based group model of 10-20 people who connect with a healthcare worker in the health facility to get their medications at the same time.
- Family member refills, a health facility-based model, where one member of a family comes to the health facility every three months for the medications of all family members.
- Outreach model, a community-based individual model, where healthcare workers travel to meet patients in the community and dispense medications.
This study was done in six public sector clinics and one public sector hospital, each catering to over 3000 people living with HIV and implementing at least one of the five models in Harare. It is interesting to note that none of the study sites was offering the club refills and outreach models for differentiated service delivery.
The researchers conducted key informant interviews with 35 healthcare workers, eight focus group discussions with 54 people living with HIV and a discrete choice experiment and survey with 500 people living with HIV who were eligible for – but not receiving care from – a differentiated service delivery model.
A discrete choice experiment requires respondents to state their preferences when presented with alternative but hypothetical scenarios. Each alternative is described by several attributes; the responses are analysed to determine which attributes significantly influence people’s choices. Discrete choice experiments can help inform the design of new services.
One of the important findings in this study is that the preferences of people living with HIV and healthcare workers were consistent in the different research methods used in the study. A humane provider attitude came up prominently in the study.
In the discrete choice experiment, the participants were more than twice as likely to choose services delivered by respectful and understanding staff, whether or not the service provider was a healthcare professional or a peer community member. They expressed lower preferences for models delivered in community settings or in their homes than models delivered in health facilities.
They preferred shorter waiting times of one-two hours over four hours, and six-monthly visits rather than three-monthly visits.
In interviews, healthcare workers also believed that health facility-based individual models were preferred by people living with HIV, and they also resulted in decongestion of health facilities and reduced their workload.
The researchers conducted key informant interviews with 35 healthcare workers, eight focus group discussions with 54 people living with HIV and a discrete choice experiment and survey with 500 people living with HIV who were eligible for – but not receiving care from – a differentiated service delivery model.
A discrete choice experiment requires respondents to state their preferences when presented with alternative but hypothetical scenarios. Each alternative is described by several attributes; the responses are analysed to determine which attributes significantly influence people’s choices. Discrete choice experiments can help inform the design of new services.
One of the important findings in this study is that the preferences of people living with HIV and healthcare workers were consistent in the different research methods used in the study. A humane provider attitude came up prominently in the study.
In the discrete choice experiment, the participants were more than twice as likely to choose services delivered by respectful and understanding staff, whether or not the service provider was a healthcare professional or a peer community member. They expressed lower preferences for models delivered in community settings or in their homes than models delivered in health facilities.
They preferred shorter waiting times of one-two hours over four hours, and six-monthly visits rather than three-monthly visits.
In interviews, healthcare workers also believed that health facility-based individual models were preferred by people living with HIV, and they also resulted in decongestion of health facilities and reduced their workload.
"Differentiated service delivery models that involved groups or community settings were not favoured."
It is interesting to note that patients were indifferent about the cadre of healthcare workers, the operating times of the health facility, or the distance from home to the health facility (even when 50% walked or 44% took public transport, and the cost associated with transport did come up as one of the challenges).
Distance from home to health facility might matter in other contexts such as rural areas or where social support is weaker. Another study published last year from Zambia showed that rural populations had some preference for community-based differentiated service delivery, while other findings were consistent with this Zimbabwean study.
The study shows a preference for less waiting time in health facilities. A third of survey participants said they usually waited for more than two hours. Waiting times must be addressed to reduce risk of hospital borne infection transmission too.
It is no surprise that those respondents who were dealing with symptoms were happy with more frequent visits (three monthly) whereas those who were more stable wanted six monthly visits to the health facility, with a preference for the fast track model.
The majority had disclosed their HIV status to at least one other person (90%) but the issue of disclosure and confidentiality came up in focus group discussions. Privacy was not always protected by healthcare workers, leading to inadvertent disclosure of HIV status to other clinic attendees.
This study also underlines that HIV stigma continues to be a barrier to health services. Participants had a preference for health facility-based models over community-based models in order to avoid meeting other members of community and inadvertently disclose their status. They also preferred the more comprehensive care at the facility.
With ten months left to meet the global UNAIDS target of 90-90-90, differentiated service delivery models that are preferred by people living with HIV should be prioritised. As the study authors note “These results are highly policy-relevant for Zimbabwe, suggesting the need to expand access to facility-based individual models in urban settings.”
Distance from home to health facility might matter in other contexts such as rural areas or where social support is weaker. Another study published last year from Zambia showed that rural populations had some preference for community-based differentiated service delivery, while other findings were consistent with this Zimbabwean study.
The study shows a preference for less waiting time in health facilities. A third of survey participants said they usually waited for more than two hours. Waiting times must be addressed to reduce risk of hospital borne infection transmission too.
It is no surprise that those respondents who were dealing with symptoms were happy with more frequent visits (three monthly) whereas those who were more stable wanted six monthly visits to the health facility, with a preference for the fast track model.
The majority had disclosed their HIV status to at least one other person (90%) but the issue of disclosure and confidentiality came up in focus group discussions. Privacy was not always protected by healthcare workers, leading to inadvertent disclosure of HIV status to other clinic attendees.
This study also underlines that HIV stigma continues to be a barrier to health services. Participants had a preference for health facility-based models over community-based models in order to avoid meeting other members of community and inadvertently disclose their status. They also preferred the more comprehensive care at the facility.
With ten months left to meet the global UNAIDS target of 90-90-90, differentiated service delivery models that are preferred by people living with HIV should be prioritised. As the study authors note “These results are highly policy-relevant for Zimbabwe, suggesting the need to expand access to facility-based individual models in urban settings.”
References:Rabkin M et al. Optimizing differentiated treatment models for people living with HIV in urban Zimbabwe: Findings from a mixed methods study. PLOS ONE, 15: e0228148, January 2020.https://doi.org/10.1371/journal.pone.0228148
