Abstract:
Introduction: In 2016, the World Health Organization recommended differentiated service delivery (DSD) as a client-centred
approach to simplify HIV care in frequency and intensity, thus reducing the clinic visit burden on individuals and HIV programmes. We describe the scale of DSD implementation among HIV facilities in low- and middle-income countries (LMICs) in
Latin America, Africa and the Asia-Pacific before the COVID-19 pandemic.
Methods: We analysed facility-level survey data from HIV care facilities participating in the International epidemiology
Databases to Evaluate AIDS consortium in 2019. We used descriptive statistics to summarise the availability of DSD, multimonth dispensing (MMD) and DSD for HIV treatment models. We explored factors associated with DSD implementation using
multivariable models.
Results: We included 175 facilities in the Asia-Pacific (n = 30), Latin America (n = 8), Central Africa (n = 21), East Africa
(n = 74), Southern Africa (n = 28) and West Africa (n = 14). Overall, 133 facilities (76%) reported implementing DSD. Of
these, 91% offered DSD for HIV treatment, 61% for HIV testing and 59% for antiretroviral therapy (ART) initiation. The most
common duration of ART refills for clinically stable clients was 3MMD, (70%), followed by monthly (14%) and 6MMD (10%).
Facility-based individual models were the most frequently available DSD for the HIV treatment model (82%), followed by
client-managed group models (60%). Out-of-facility individual models were available at 48% of facilities. Facility-based individual models were particularly common among facilities in East (92%) and Southern Africa (96%). Facilities in medium and high
HIV prevalence countries, and those with 3MMD, were more likely to implement DSD.
Conclusions: In 2019, DSD was available in most HIV care facilities globally but was not evenly implemented across regions
and HIV services. Most offered facility-based DSD for HIV treatment models and 3MMD for clinically stable clients. Efforts to
expand DSD for HIV testing and ART initiation and to offer longer MMD can improve long-term retention in care of people
living with HIV in LMICs, while further alleviating the operational burden on healthcare services. These findings from the preCOVID-19 era underline the need for strengthening DSD in HIV care, which remains at the centre of current efforts towards
client-centred care.
