Client and healthcare worker experiences with differentiated HIV treatment models in Eswatini

Abstract

Introduction Universal access to antiretroviral therapy (ART) is a cornerstone of Eswatini’s national HIV strategy, and the number of people on ART in the country more than tripled between 2010 and 2019. Building on these achievements, the Ministry of Health (MOH) is scaling up differentiated service delivery, including less-intensive differentiated ART (DART) models for people doing well on treatment. We conducted a mixed-methods study to explore client and health care worker (HCW) perceptions of DART in Eswatini. Methods The study included structured site assessments at 39 purposively selected health facilities (HF), key informant interviews with 20 HCW, a provider satisfaction survey with 172 HCW and a client satisfaction survey with 270 adults. Results All clients had been on ART for more than a year; 69% were on ART for ≥ 5 years. The most common DART models were Fast-Track (44%), Outreach (26%) and Community ART Groups (20%). HCW and clients appreciated DART, noting that the models often decrease provider workload and client wait time. Clients also reported that DART models helped them to adhere to ART, 96% said they were “very satisfied” with their current model, and 90% said they would recommend their model to others, highlighting convenience, efficiency and cost savings. The majority of HCW (52%) noted that implementation of DART reduced their workload, although some models, such as Outreach, were more labor-intensive. Each model had advantages and disadvantages; for example, clients concerned about stigma and inadvertent disclosure of HIV status were less interested in group models. Conclusions Clients in DART models were very satisfied with their care. HCW were also supportive of the new approach to HIV treatment delivery, noting its advantages to HF, HCW and to clients. Given the heterogeneous needs of people living with HIV, no single DART model will suit every client; a diverse portfolio of DART models is likely the best strategy.

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.…”

“…Our results also add to the existing body of research on self-reported provider workload following DSD implementation in other sub-Saharan African countries. Healthcare workers from Eswatini reported decreased workload, reduced clinic congestion, and shorter patient waiting times following the implementation of DSD models (31). Providers in Mozambique reported an overall improvement in quality of care due to reduced provider workload, which allowed them to attend to more complicated patients (32).…”

Satisfaction with service delivery among HIV treatment clients enrolled in differentiated and conventional models of care in South Africa: a baseline survey

“…Our findings are consistent with those of previous studies assessing overall satisfaction with routine HIV care in high HIV burden settings [ 24 , 25 , 26 ]. A study in Eswatini found that 96% of study participants were satisfied with their current ART delivery model, and 90% recommended it to others [ 17 ]. Recipients of care from Khayelitsha in Cape Town, South Africa, also reported generally positive experiences with DSD model care [ 27 ], and 64.2% of those enrolled in DSD model care in Uganda reported high satisfaction with the treatment [ 18 ].…”

“…Recipients of care from Khayelitsha in Cape Town, South Africa, also reported generally positive experiences with DSD model care [ 27 ], and 64.2% of those enrolled in DSD model care in Uganda reported high satisfaction with the treatment [ 18 ]. These prior studies did not compare satisfaction with DSD model care with conventional care [ 17 , 18 , 28 ]. This study contributes to the knowledge base by providing this comparison, finding that those in DSD models are more likely to express satisfaction with their care.…”

“…Little is known, however, about how patient experiences in DSD models differ from those in conventional care. Recent studies showed high levels of self‐reported satisfaction ranging from 60% to 96% among ART clients in DSD models [ 17 , 18 ], with higher satisfaction among those participating in out‐of‐facility models than those in facility‐based models [ 18 ]. These studies do not compare satisfaction among recipients of care in DSD models to that of recipients of care remaining in conventional care, however.…”