Expanding the Vision for Differentiated Service Delivery: A Call for More Inclusive and Truly Patient-Centered Care for People Living With HIV

Abstract

Background: Simplifying antiretroviral therapy for clinically stable people living with HIV (PLHIV) is important but insufficient to meet their health care needs, including prevention and treatment of tuberculosis and noncommunicable diseases, routine primary care, and family planning. Integrating these services into differentiated service delivery (DSD) platforms is a promising avenue to achieve such coverage. We propose a transition from an HIV-focused “DSD 1.0” to a patient-centered “DSD 2.0” that is inclusive of additional chronic care services for PLHIV. Discussion: The lack of coordination between HIV programs and these critical services puts a burden on both PLHIV and health systems. For individual patients, fractionated services increase cost and time, diminish the actual and perceived quality of care, and increase the risk that they will disengage from health care altogether. The burden on the health system is one of inefficiency and suboptimal outcomes resulting from the parallel systems required to manage multiple vertical programs. Conclusions: DSD 2.0 provides an opportunity for the HIV and Universal Health Coverage agendas—which can seem to be at odds—to achieve greater collective impact for patients and health systems by integrating strong vertical HIV, tuberculosis and family planning programs, and relatively weaker noncommunicable disease programs. Increasing coordination of care for PLHIV will increase the likelihood of achieving and sustaining UNAIDS′ goals of retention on antiretroviral therapy and viral suppression. Eventually, this shift to DSD 2.0 for PLHIV could evolve to a more person-centered vision of chronic care services that would also serve the general population.

Acceleration of differentiated service delivery for HIV treatment in sub‐Saharan Africa during COVID‐19

“…Specific populations, including children, adolescents and pregnant and breastfeeding women, as well as people living with HIV and other comorbidities were largely excluded from accessing DSD. Furthermore, TB preventive therapy (TPT) and family planning commodities were not aligned or integrated within DSD for HIV treatment models and key populations continued to have limited access [6,7].…”

Silver linings: how COVID‐19 expedited differentiated service delivery for HIV

“…argue for the expansion of DSD for HIV treatment models to include tuberculosis treatment [ 27 ]. We agree—and while policy provisions were made in some countries to align HIV services and the delivery of other health commodities like family planning or medications for non‐communicable diseases, very little data on the implementation of these policies are available [ 6 , 28 ].…”

Changes in HIV treatment differentiated care uptake during the COVID‐19 pandemic in Zambia: interrupted time series analysis

“…1 Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA; 2 Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA; 3 Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; 4 Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA; 5 Clinton Health Access Initiative, Lusaka, Zambia; 6 Ministry of Health, Lusaka, Zambia; 7 The Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; 8 Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands…”

“…Maintenance of ART services -in addition to continued case identification and prompt initiation of newly diagnosed PLHIV on lifelong treatment -is critical to protect the progress that has been made towards HIV epidemic control [2]. One potential solution to the disruptions caused by COVID-19 is differentiated service delivery (DSD), a "clientcentered approach that simplifies and adapts HIV services across the cascade to serve the needs of PLHIV better and reduce unnecessary burdens on the health system" [3]. DSD has emerged as a key strategy for HIV programmes in resource-limited settings, as DSD models can lessen the burden of HIV treatment on clients and providers by extending medication dispensing intervals, reducing requirements for…”

“…One potential solution to the disruptions caused by COVID‐19 is differentiated service delivery (DSD), a “client‐centered approach that simplifies and adapts HIV services across the cascade to serve the needs of PLHIV better and reduce unnecessary burdens on the health system” [ 3 ]. DSD has emerged as a key strategy for HIV programmes in resource‐limited settings, as DSD models can lessen the burden of HIV treatment on clients and providers by extending medication dispensing intervals, reducing requirements for facility visits and adjusting the location of service delivery [ 4 ].…”