Availability and experiences of differentiated antiretroviral therapy delivery at HIV care facilities in rural Zimbabwe: a mixed‐method study

Abstract

Introduction Zimbabwe adopted differentiated HIV care policies in 2015 to promote client‐centred care and relieve strain on health facilities. We examined the availability, experiences and perceptions of differentiated antiretroviral therapy (ART) delivery in rural Zimbabwe following the policy adoption. Methods We undertook a cross‐sectional mixed methods study in all the 26 facilities providing HIV care in a rural district in Zimbabwe. We collected quantitative data about ART delivery and visit durations from 31 healthcare providers and a purposive stratified sample of 378 clients obtaining ART either through routine care or differentiated ART delivery models. We performed 26 semi‐structured interviews among healthcare providers and seven focus group discussions (FGDs) among clients to elicit their perceptions and experiences of ART delivery. Data were collected in 2019, with one follow‐up FGD in 2021. We analysed the transcripts thematically, with inductive coding, to identify emerging themes. Results Twenty facilities (77%) offered at least one differentiated ART delivery models, including community ART refill groups (CARGs; 13 facilities, 50%), fast‐track refill (8, 31%), family refill (6, 23%) or club refill (1, 4%). Thirteen facilities (50%) offered only one model. The median visit duration was 28 minutes (interquartile range [IQR]: 16–62). Participants in fast‐track had the shortest visit durations (18 minutes, IQR: 11–24). Confidentiality and disclosure of HIV status, travelling long distances, travel costs and waiting times were the main issues influencing clients’ views on differentiated ART delivery. Fast‐track refill was perceived as the preferred model of clients for its limited involuntary disclosure and efficiency. In contrast, group‐ and community‐based refill models reduced travel costs but were felt to be associated with involuntary disclosure of HIV status, which could discourage clients. Healthcare providers also experienced an additional workload when offering facility‐based group models, such as CARGs. Conclusions Differentiated ART delivery models were widely available in this rural setting, but most facilities did not offer a choice of models to address clients’ diverse preferences. A minority offered fast‐track refills, although this model was often mentioned as desirable. Confidentiality, travel expenses and client waiting times are key elements to consider when planning and rolling out differentiated HIV care.

Effect of differentiated service delivery models for HIV treatment on healthcare providers’ job satisfaction and workloads in sub-Saharan Africa: a mixed methods study from Malawi, Zambia, and South Africa

“…Although most responses were positive in terms of working conditions, a minority of respondents in all three countries stated that the introduction of DSD models reduced their job satisfaction, due mainly to additional administrative duties and lack of human and nancial resources at their facilities. This was more commonly reported by South African respondents and mirrors ndings from studies in Zimbabwe (34) and Eswatini (31), in which providers reported that having to ll prescriptions for community-based models added to their job burdens.…”

“They provide the right kind of support.”A qualitative study of preferences for differentiated service delivery location among recipients of antiretroviral therapy at Lighthouse Trust in Lilongwe Malawi

“…RoC in both locations were concerned with privacy and the potential for stigma, making a deliberate choice to remain in their care location to avoid HIV-related stigma. While DSD is scaling up, frequently to community settings, previous studies suggest fear of unintended disclosure as a barrier to uptake of community-based DSD models [5,6,8,11,12,26]. In our study, some clinic-based RoC compromised travel and time concerns to receive care at LT, rather than in the community, to avoid being seen receiving HIV-related services.…”

“…Recent qualitative studies explored RoC and provider experiences in HIV care with DSDs. RoC in community-based models reported that fewer clinic visits reduce their clinic wait times and transportation costs [5–7], increase peer support [8,9] and improve treatment adherence [10]. By contrast, clinic-based RoC in SSA reported preferring clinic-based care to community-based refill options because the clinics were near work [5] or they feared stigma and discrimination of inadvertent disclosure of their HIV status if they collected ART at a community venue [5,6,8,11,12].…”

“…RoC in community-based models reported that fewer clinic visits reduce their clinic wait times and transportation costs [5–7], increase peer support [8,9] and improve treatment adherence [10]. By contrast, clinic-based RoC in SSA reported preferring clinic-based care to community-based refill options because the clinics were near work [5] or they feared stigma and discrimination of inadvertent disclosure of their HIV status if they collected ART at a community venue [5,6,8,11,12]. Healthcare providers also reported that RoC’s concerns around confidentiality and unwanted disclosure of HIV status posed barriers to using clinic-based DSD models [5].…”

“…By contrast, clinic-based RoC in SSA reported preferring clinic-based care to community-based refill options because the clinics were near work [5] or they feared stigma and discrimination of inadvertent disclosure of their HIV status if they collected ART at a community venue [5,6,8,11,12]. Healthcare providers also reported that RoC’s concerns around confidentiality and unwanted disclosure of HIV status posed barriers to using clinic-based DSD models [5]. It is possible that RoC may have different reasons for accessing ART care at clinics or community sites, and perspectives from RoC in routine HIV care with both clinic and community-based DSD options are lacking.…”