Differentiated HIV care in sub-Saharan Africa: a scoping review to inform antiretroviral therapy provision for stable HIV-infected individuals in Kenya

Abstract

Many gaps in care exist for provision of antiretroviral therapy (ART) in sub-Saharan Africa. Differentiated HIV care tailors provision of ART for patients based on their level of acuity, providing alternatives for where, by whom, and how often care occurs. We conducted a scoping review to assess novel differentiated care models for ART provision for stable HIV-infected adults in sub-Saharan Africa, and how these models can be used to guide differentiated care implementation in Kenya. A systematic search was conducted using PubMed, Embase, Web of Science, Popline, Cochrane Library, and African Index Medicus between January 2006 and January 2017. Grey literature searches and handsearching were also used. We included articles that quantitatively assessed the health, acceptability, and cost-effectiveness of differentiated HIV care. Two reviewers independently performed article screening, data extraction and determination of inclusion for analysis. We included 40 publications involving over 240,000 participants spanning nine countries in sub-Saharan Africa - 54.4% evaluated clinical outcomes, 23.5% evaluated acceptability outcomes, and 22.1% evaluated cost outcomes. Differentiated care models included: facility fast-track drug refills and appointment spacing, facility or community-based ART groups, community ART distribution points or home-based care, and task-shifting or decentralization of care. Studies suggest that these approaches had similar outcomes in viral load suppression and retention in care and were acceptable alternatives to standard HIV care. No clear results could be inferred for studies investigating task shifting and those reporting cost-effectiveness outcomes. Kenya has started to scale up differentiated care models, but further evaluation, quality improvement and research studies should be performed as different models are rolled out.

Retention in care and viral suppression in differentiated service delivery models for HIV treatment delivery in sub‐Saharan Africa: a rapid systematic review

“…Search strings and a full list of conferences included can be found in Table . Limiting eligible articles and abstracts to those published or presented since 2016 was intended to ensure that results come as close as possible to reflecting the current state of DSD model implementation and to avoid repeating the efforts of previous reviews [2,10‐13]. If a source reported patient follow‐up data collected both before and after January 1, 2016, we included it only if the majority of follow‐up time (more than 50%), as stated in the source or estimated by the authors, occurred after that date.…”

Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study

“…As the number of people on ART in low-income countries increases, the challenges of delivering lifelong treatment become harder to tackle and require innovative solutions to ensure efficient services, without compromising on quality. Given that approximately one third of patients initiated on ART are documented as lost to follow-up (LTFU) within 2 years [4,5], national HIV programmes are building strategies to ensure that more patients remain in care [6][7][8].…”

Patient experiences of ART adherence clubs in Khayelitsha and Gugulethu, Cape Town, South Africa: A qualitative study

“…Several sub-Saharan African countries including Uganda, Kenya, the Democratic Republic of Congo, Malawi and Mozambique have implemented differentiated models of ART delivery [4, 8–11]. The ART adherence club (AC) model is a healthcare worker managed group model designed to meet the needs of clinically stable adult ART patients.…”