Expansion of a national differentiated service delivery model to support people living with HIV and other chronic conditions in South Africa: a descriptive analysis

Abstract

Background South Africa is home to 7.7 million people living with HIV and supports the largest antiretroviral therapy (ART) program worldwide. Despite global investment in HIV service delivery and the parallel challenge of non-communicable diseases (NCDs), there are few examples of integrated programs addressing both HIV and NCDs through differentiated service delivery. In 2014, the National Department of Health (NDoH) of South Africa launched the Central Chronic Medicines Dispensing and Distribution (CCMDD) program to provide patients who have chronic diseases, including HIV, with alternative access to medications via community-based pick-up points. This study describes the expansion of CCMDD toward national scale. Methods Yale monitors CCMDD expansion as part of its mixed methods evaluation of Project Last Mile, a national technical support partner for CCMDD since 2016. From March 2016 through October 2019, cumulative weekly data on CCMDD uptake [patients enrolled, facilities registered, pick-up points contracted], type of medication provided [ART only; NCD only; and ART-NCD] and collection sites preferred by patients [external pick-up points; adherence/outreach clubs; or facility-based fast lanes], were extracted for descriptive, longitudinal analysis. Results As of October 2019, 3,436 health facilities were registered with CCMDD across 46 health districts (88 % of South Africa’s districts), and 2,037 external pick-up points had been contracted by the NDoH. A total of 2,069,039 patients were actively serviced through CCMDD, a significant increase since 2018 (p < 0.001), including 76 % collecting ART [64 % ART only, 12 % ART plus NCD/comorbidities] and 479,120 [24 %] collecting medications for chronic diseases only. Further, 734,005 (35 %) of patients were collecting from contracted, external pick-up points, a 73 % increase in patient volume from 2018. Discussion This longitudinal description of CCMDD provides an example of growth of a national differentiated service delivery model that integrates management of HIV and noncommunicable diseases. This study demonstrates the success of the program in engaging patients irrespective of their chronic condition, which bodes well for the potential of the program to address the rising burden of both HIV and NCDs in South Africa. Conclusions The CCMDD program expansion signals the potential for a differentiated service delivery strategy in resource-limited settings that can be agnostic of the patients chronic disease condition.

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

“…Many of the remaining gaps require data from implementation science, such as the paucity of evidence available on the integration of HIV services with other disease areas [ 29 ]. Further analyses of routine data on how COVID‐19 adaptions impacted outcomes are also encouraged, including the effect of earlier access to MMD, particularly from ART initiation as well as for specific populations namely children and adolescents, those who are pregnant and breastfeeding and migrant populations.…”

PEPFAR’s Role in Protecting and Leveraging HIV Services in the COVID-19 Response in Africa

“…Many PEPFAR countries prioritized the maintenance and acceleration of PrEP services by ensuring adherence and continuity with existing clients and offering multi-month dispensing (MMD) [ 9 ]. Recognizing the need for non-facility-based delivery modalities, South Africa innovated with home and community delivery and online ordering of PrEP, including condoms, lubricants, and self-screening test kits [ 10 ]. Lesotho shifted PrEP initiations and refills from large community outreach events to drop-in centers for key and priority populations, while integrating it with other services such as family planning.…”

“…PEPFAR also promoted decentralized drug delivery, in which clients collect their medication at a site away from health facilities, such as a private pharmacy or community center. In South Africa, the proportion of individuals receiving medication from an alternate pick-up site increased from 34 to 50% shortly after the start of the pandemic [ 10 ]. Nigeria implemented home delivery of antiretrovirals ARVs using treatment supporters and peer navigators all aimed at ensuring continuity of treatment.…”

Differentiated service delivery for people using second‐line antiretroviral therapy: clinical outcomes from a retrospective cohort study in KwaZulu‐Natal, South Africa

“…In September 2016, the country adopted the policy of universal test and treat, which aims to provide ART to all 7.8 million people living with HIV (PLHIV) regardless of CD4 count [ 2 ]. To efficiently achieve universal ART and the UNAIDS 95‐95‐95 targets, the country has implemented the Centralized Chronic Medicines Dispensing and Distribution (CCMDD) programme [ 3 , 4 ], which has been used to support the rollout of both community‐ and facility‐based differentiated ART delivery [ 5 ]. In the community‐based ART delivery programme, PLHIV can collect ART in more convenient locations, such as community pickup points and private pharmacies, rather than at clinics [ 3 , 4 , 6 , 7 ].…”

“…To efficiently achieve universal ART and the UNAIDS 95‐95‐95 targets, the country has implemented the Centralized Chronic Medicines Dispensing and Distribution (CCMDD) programme [ 3 , 4 ], which has been used to support the rollout of both community‐ and facility‐based differentiated ART delivery [ 5 ]. In the community‐based ART delivery programme, PLHIV can collect ART in more convenient locations, such as community pickup points and private pharmacies, rather than at clinics [ 3 , 4 , 6 , 7 ]. There is a growing body of evidence supporting the use of such differentiated ART delivery programmes among PLHIV who are stable on first‐line ART [ 8 , 9 ], in order to provide more efficient, client‐centred care and decongest clinics.…”