A mixed-methods evaluation of the uptake of novel differentiated ART delivery models in a national sample of health facilities in Uganda

Abstract

Introduction Since 2017, Uganda has been implementing five differentiated antiretroviral therapy (ART) delivery models to improve the quality of HIV care and to achieve health-system efficiencies. Community-based models include Community Client-Led ART Delivery and Community Drug Distribution Points. Facility-based models include Fast Track Drug Refill, Facility Based Group and Facility Based Individual Management. We set out to assess the extent of uptake of these ART delivery models and to describe barriers to uptake of either facility-based or community-based models. Methods Between December 2019 and February 2020, we conducted a mixed-methods study entailing a cross-sectional health facility survey (n = 116) and in-depth interviews (n = 16) with ART clinic managers in ten case-study facilities as well as six focus group discussions (56 participants) with patients enrolled in differentiated ART models. Facilities were selected based on the 10 geographic sub-regions of Uganda. Statistical analyses were performed in STATA (v13) while qualitative data were analysed by thematic approach. Results Most facilities 63 (57%) commenced implementation of differentiated ART delivery in 2018. Fast Track Drug Delivery was the most common facility-based model (implemented in 100 or 86% of health facilities). Community Client-Led ART Delivery was the most popular community model (63/116 or 54%). Community Drug Distribution Points had the lowest uptake with only 33 (24.88%) facilities implementing them. By ownership-type, for-profit facilities reported the lowest uptake of differentiated ART models. Barriers to enrolment in community-based models include HIV-related stigma and low enrolment of adult males in community models. Conclusion To the best of our knowledge this is the first study reporting national coverage of differentiated ART delivery models in Uganda. Overall, there has been a higher uptake of facility-based models. Interventions for enhancing the uptake of differentiated ART models in for-profit facilities are recommended.

Uptake of community‐ versus clinic‐based antiretroviral therapy dispensing in the Central Chronic Medication Dispensing and Distribution program in South Africa

“…Studies on patient preferences between community‐ and clinic‐based ART delivery have found clinic‐based services to be favoured, especially in urban settings [ 44 , 45 , 46 , 47 ]. In Johannesburg adherence clubs, patients were more likely to recommend joining if they were in clinic‐ versus community‐based clubs [ 48 ].…”

Evaluation of HIV treatment outcomes with reduced frequency of clinical encounters and antiretroviral treatment refills: A systematic review and meta-analysis

“…While we found overall little difference in clinical outcomes for reduced visit frequency, there are other potential benefits of reduced visits, including decongestion of health facilities, reduced provider workload, prioritization of care for new or clinically unstable PLWH, and reduced transmission of COVID-19 in health centers [ 5 , 13 , 41 – 44 ]. Reducing visit frequency has been reported to be one of the easiest DSD models to implement and aligns strongly with the care preferences of PLWH by reducing the economic costs of attending frequent appointments, reducing stigma, and allowing PLWH to normalize HIV [ 3 , 4 , 10 , 11 , 45 , 46 ]. HIV services, however, need to remain flexible enough to accommodate return to facilities for those who opt back into standard care or when clinical requirements change [ 27 ].…”

“…HIV services, however, need to remain flexible enough to accommodate return to facilities for those who opt back into standard care or when clinical requirements change [ 27 ]. Further research is needed to develop strategies that allow for transition between models of care and provide psychosocial support between extended visits (e.g., virtual visits or group models) [ 3 , 47 ]. As many countries, in response to COVID-19, have expanded multi-month dispensing for patients who have not previously been considered established on ART [ 12 ], it will be essential to explore outcomes in those less “established” on ART, as well as to develop strategies to align and integrate non-communicable disease care with these models and to identify optimum models of care for key populations, other regions, and children, to ensure the utility of these models for all PLWH [ 5 , 48 ].…”

“…There is, however, concern that reduced frequency might also compromise meaningful clinical and psychosocial interactions with the health system and potentially, paradoxically, increase missed appointments or non-adherence over the long term. Most existing data support the hypothesis that longer intervals reduce obstacles to attending services for PLWH, including structural challenges such as the time and travel required to attend appointments and pick up medications—which result in considerable direct and indirect costs—as well as psychosocial barriers such as stigma [ 3 – 7 ].…”

“…Early data syntheses suggesting that outcomes are equivalent for 3- versus 1-monthly appointments [ 8 , 9 ] do not automatically apply to further extensions. Qualitative, survey, and preference data indicate that PLWH value DSD models that include lengthened appointment intervals [ 4 , 10 , 11 ], but also that some PLWH do prefer more frequent psychosocial support from interactions with their providers [ 3 ]. Implementation of reduced visit frequency has accelerated pace in the past 2 years as it has become a practical necessity during the COVID-19 pandemic to decongest health facilities and limit physical contact [ 12 , 13 ].…”