Delivering HIV care in challenging operating environments: the MSF experience towards differentiated models of care for settings with multiple basic health care needs

Abstract

Introduction: Countries in the West and Central African regions struggle to offer quality HIV care at scale, despite HIV prevalence being relatively low. In these challenging operating environments, basic health care needs are multiple, systems are highly fragile and conflict disrupts health care. Médecins Sans Frontières (MSF) has been working to integrate HIV care in basic health services in such settings since 2000. We review the implementation of differentiated HIV care and treatment approaches in MSF-supported programmes in South Sudan (RoSS), Central African Republic (CAR) and Democratic Republic of Congo (DRC).Methods: A descriptive analysis from CAR, DRC and RoSS programmes reviewing methodology and strategies of HIV care integration between 2010 and 2015 was performed. We describe HIV care models integrated within the provision of general health care and highlight best practices and challenges.Results: Services included provision of general health care, with out-patient care (range between countries 43,343 and 287,163 consultations/year in 2015) and in-patient care (range 1076–16,595 in 2015). By the end of 2015 antiretroviral therapy (ART) initiations reached 12–255 patients/year. A total of 1101 and 1053 patients were on ART in CAR and DRC, respectively. In RoSS 186 patients were on ART when conflict recommenced late in 2013. While ART initiation and monitoring were mostly clinically driven in the early phase of the programmes, DRC implemented CD4 monitoring and progressively HIV viral load (VL) monitoring during study period. Attacks to health care facilities in CAR and RoSS disrupted service provision temporarily. Programmatic challenges include: competing health priorities influencing HIV care and need to integrate within general health services. Differentiated care approaches that support continuity of care in these programmes include simplification of medical protocols, multi-month ART prescriptions, and community strategies such as ART delivery groups, contingency plans and peer support activities.Conclusions: The principles of differentiated HIV care for high-quality ART delivery can successfully be applied in challenging operating environments. However, success heavily depends on specific adaptations to each setting.

The time is now: expedited HIV differentiated service delivery during the COVID‐19 pandemic

“…In Sierra Leone, peers started collecting and distributing ART refills to patients’ homes or from community meeting points [18]. In response to conflict in the Central African Republic in 2015, patients were provided with 6‐month refills distributed by lay healthcare workers from decentralized peripheral health facilities [19]. More recently, in 2019 during armed conflict in the Cabo del Gado province of Mozambique, mobile clinics provided outreach and ART refills within communities [20].…”

Evidence for scale up: the differentiated care research agenda

“…Their findings present novel evidence of the success of differentiated ART delivery for stable clients in a concentrated HIV epidemic. Work from South Sudan, the Central African Republic and the DRC is shared in the article by Ssonko et al, differentiating ART services both for ART initiation and delivery, were implemented to support client outcomes in challenging environments [ 34 ]. Finally, a commentary by Nsanzimana et al on the phased implementation of an individual facility-based model in the Rwandan national HIV programme emphasizes the relevance of differentiated ART delivery in Rwanda [ 35 ], a low-prevalence HIV setting [ 36 ,37].…”

A Qualitative Assessment of Provider and Client Experiences With 3- and 6-Month Dispensing Intervals of Antiretroviral Therapy in Malawi

“…1,3 Examples of ART DMOCs that have been implemented in sub-Saharan Africa include community-based ART groups, adherence clubs, fast-track refills, mobile clinics, and multimonth dispensing (MMD). [8][9][10] The MMD model increases the quantity of ART received at one time and subsequently reduces the frequency of client facility visits. 11 Guided by the U.S. President's Emergency Plan for AIDS Relief, longer dispensing intervals (up to 6 months of ART) are being implemented across Africa 1,7,[12][13][14] ; however, large-scale implementation experience with this model of care is lacking.…”