A pragmatic approach to monitor and evaluate implementation and impact of differentiated ART delivery for global and national stakeholders

Abstract

IntroductionThe World Health Organization's (WHO) recommendation of “Treat All” has accelerated the call for differentiated antiretroviral therapy (ART) delivery, a method of care that efficiently uses limited resources to increase access to HIV treatment. WHO has further recommended that stable individuals on ART receive refills every 3 to 6 months and attend clinical visits every 3 to 6 months. However, there is not yet consensus on how to ensure that the quality of services is maintained as countries strive to meet these standards. This commentary responds to this gap by defining a pragmatic approach to the monitoring and evaluation (M&E) of the scale up of differentiated ART delivery for global and national stakeholders.DiscussionProgramme managers need to demonstrate that the scale up of differentiated ART delivery is achieving the desired effectiveness and efficiency outcomes to justify continued support by national and global stakeholders. To achieve this goal, the two existing global WHO HIV treatment indicators of ART retention and viral suppression should be augmented with two broad aggregate measures. The addition of indicators measuring the frequency of (1) clinical and (2) refill visits by PLHIV per year will allow evaluation of the pace of scale up while monitoring its overall effect on the quality and efficiency of services. The combination of these four routinely collected aggregate indicators will also facilitate the comparison of outcomes among facilities, regions or countries implementing different models of ART delivery. Enhanced monitoring or additional assessments will be required to answer other critical questions on the process of implementation, acceptability, effectiveness and efficiency.ConclusionsThese proposed outcomes are useful markers for the effectiveness and efficiency of the health system's attempts to deliver quality treatment to those who need it—and still reserve as much of the available resource pool as possible for other key elements of the HIV response.

Research priorities to inform “Treat All” policy implementation for people living with HIV in sub‐Saharan Africa: a consensus statement from the International epidemiology Databases to Evaluate AIDS (IeDEA)

“… Context: With the rollout of Treat All, the public health approaches that have been effective in the rapid scale‐up of treatment to date may not be sufficient for reaching the 90‐90‐90 targets and achieving epidemic control . For the general population and key population groups (e.g.…”

VIBRA trial – Effect of village-based refill of ART following home-based same-day ART initiation vs clinic-based ART refill on viral suppression among individuals living with HIV: protocol of a cluster-randomized clinical trial in rural Lesotho

“…54,55 Therefore, there is global consensus that new differentiated care and service delivery models that increase the capacity, efficiency and cost-effectiveness of delivering ART without reducing quality of care are urgently needed. 22,41,56 Task-shifting to lay health workers in the community is a promising approach and in line with the current UNAIDS initiative. 44 However, at community-level, task-shifting usually focuses on adherence monitoring, not provision of antiretroviral drugs.…”

Peer Recruitment Strategies for Female Sex Workers Not Engaged in HIV Prevention and Treatment Services in Côte d’Ivoire: Program Data Analysis

“…Since peer referral approaches have been well established as useful in recruiting marginalized populations for research studies and have previously been leveraged as intervention tools to influence HIV-related behavior and improve HIV outcomes [ 33 , 34 ], enhanced peer outreach could be used not only to increase testing uptake—an important application for differentiated care at the first step of the cascade—but also to promote HIV prevention knowledge, pre-exposure prophylaxis and condoms, thus modifying risk behaviors within networks [ 28 , 35 ]. However, these approaches have rarely been taken to scale limiting their public health impact to date [ 23 , 36 ]. Characterizing optimal implementation strategies to maximize impact and sustainability requires engagement with a broad range of stakeholders under the leadership of government and community actors [ 23 , 36 ].…”

“…However, these approaches have rarely been taken to scale limiting their public health impact to date [ 23 , 36 ]. Characterizing optimal implementation strategies to maximize impact and sustainability requires engagement with a broad range of stakeholders under the leadership of government and community actors [ 23 , 36 ].…”