Differentiated antiretroviral therapy delivery in rural Zimbabwe: availability, needs and challenges

Abstract

Introduction: The traditional “one-size-fits-all” model of HIV care whereby people living with HIV (PLWH) have regular individual clinical visits does not reflect the various preferences and needs of PLWH and stretches the capacity of health facilities (HFs). Little is known about the availability and the experience of differentiated HIV care delivery in the rural areas of Zimbabwe.Methods: We used a mixed-method approach to collect data from clients and providers at 26 HFs in Zimbabwe in 2019. We collected quantitative data about antiretroviral therapy (ART) delivery and time spent at the HF during a visit from one representative healthcare providers (HCP) and a stratified sample of PLWH at each HF. We performed semi-structured interviews among HCPs and focus group discussions (FGDs) among PLWH to collect information about the implementation of differentiated ART delivery (DART) models and their experience. We performed linear regression models to assess factors associated with the time spent in the HFs. We analyzed the interviews using an inductive approach. Transcripts were coded and constricted down to themes significant to the research objectives.Results: The majority (77%) of participating HFs offered at least one of the five DART models recommended in Zimbabwe: 13 (50%) offered community ART refill group (CARG), 1 (4%) club refill, 6 (23%) family refill, and 8 (31%) fast-track refill models. Mobile outreach was not available at any participating HF. In an unadjusted linear model, PLWH enrolled in the fast-track refill model spent 0.40 (95% confidence interval (CI): 0.15-0.56) less time at the HF than PLWH on routine care, whereas PLWH in the family refill model and delegated to go to the HF spent 2.63 (95% CI 1.42-4.88) more time at the HF during visit. Confidentiality and disclosure concerns were highlighted as the major barriers affecting the implementation of DART models, together with travel costs and waiting times. HCPs reported on the challenge of excessive workloads. Fast-track refill was perceived as the most adapted DART model to meet clients’ needs, followed by CARG and family refill.Conclusions: Confidentiality, travel costs and waiting times are key elements to consider in the implementation of differentiated care in rural Zimbabwe. More implementation research is needed to support the roll-out of differentiated HIV services in that region, especially DART models addressing the needs of PLWH. Our study supports the call for personalized care at ART programs in rural Africa.

Barriers and facilitators to the implementation and scale up of differentiated service delivery models for HIV treatment in Africa: a scoping review

“…➢ The additional workload involved in packaging and labeling antiretrovirals for each member while decentralization of drug delivery to communities [ 59 , 70 ]…”

“…From the patients’ side, a perceived higher need for privacy and confidentiality [ 14 , 47 , 59 , 70 ], comprehensive health checks before taking necessary medications [ 49 ], reduced travel costs [ 14 , 52 , 53 , 55 , 68 ], reduced waiting time [ 14 , 15 , 52 , 67 , 70 ] and increased time for income-generating activities [ 55 , 68 ] were reported as the enablers for model implementation. Reduction in staff workload [ 15 , 47 , 52 , 53 , 55 , 67 , 68 ] and decongestion of health facilities with clients [ 15 , 47 , 52 , 53 , 67 ] were supply-side facilitators commonly reported in the included studies for model implementation.…”

“…Similarly, fear of detachment from the health facility [ 59 ], fear of clashing with peers [ 50 ], and dissatisfaction with the efficiency of drug pickups at the community level [ 14 ] were also patient-related barriers reported by the included studies. Medical record disorganization [ 14 ], the additional workload involved in packaging and labeling drugs for each member [ 59 , 70 ], difficulty in finding competent and literate community client-led model leaders [ 59 ], and frequent changes in physical addresses among urban clients [ 59 ] were reported barriers for model implementation from the providers’ perspective.…”

Tracing People Living With Human Immunodeficiency Virus Who Are Lost to Follow-up at Antiretroviral Therapy Programs in Southern Africa: A Sampling-Based Cohort Study in 6 Countries

“…Attrition along the care cascade is common [1][2][3][4][5]. In resource-limited settings, the long distances to clinics, costs of travel, long waiting times, as well as stigma and discrimination can deter clients from attending appointments [6][7][8][9][10][11]. Undocumented, silent transfers from one clinic to another can erroneously result in a client being classified as lost to care.…”

Addressing Failures in Achieving Hypertension Control in Low- and Middle-Income Settings through Simplified Treatment Algorithms

“…As an enabler of DSD, SAANE algorithms may improve retention in care and sustain hypertension control [ 42 ], reducing long-term complications of hypertension and, ultimately, mortality [ 43 ]. The benefits of such DSD models have been demonstrated in ART delivery, reducing both transport and opportunity costs for people and often reducing waiting times [ 44 45 46 ] when clinic visits are required – also a likely benefit of SAANE algorithms for hypertension. The provision of care at decentralized facilities by less specialized health workers also brings care closer to the person’s home, reducing their out-of-pocket transport costs and time off work or away from family responsibilities.…”