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Welcome to the third differentiated service delivery (DSD) newsletter of IAS – the International AIDS Society – in 2021. In this edition, we spotlight the latest DSD research arising from IAS 2021 – the 11th IAS Conference on HIV Science.
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DSD for HIV in times of COVID-19:
Reflections on IAS 2021
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Mwanza Wa Mwanza, Director for Clinical Care Services at the Centre for Infectious Disease Research in Zambia (CIDRZ), writes:
At IAS 2021, held virtually on 18-21 July, a large number of abstracts and presentations demonstrated the resilience of HIV programmes, communities and people living with HIV in mitigating the effects of the COVID-19 pandemic on health systems.
In South Africa, a rapid rebound in HIV service utilization among key populations was observed in the weeks following initial service interruptions. This was thanks to service delivery innovations, including increased mobile testing, ART home delivery and increased peer navigation. In Kenya, longer appointment spacing significantly increased during the COVID-19 period, enabling continuity of HIV service delivery. DSD model adaptations implemented by FHI 360 in five Kenyan counties led to improvements in viral load testing coverage and suppression rates despite challenges posed by COVID-19.
Across sub-Saharan Africa, countries made multi-month dispensing (MMD) of antiretroviral therapy (ART) available for children, as shown in this PEPFAR programme data analysis. This analysis of routine data from Zambia showed that providing a minimum three-month dispensing of ART to children from the age of two years had no adverse impact on their viral load coverage or suppression. A rapid scale up of providing people aged 15 years and older in Zambia with six-month ART refills led to an improvement in retention rates.
A key take-home message from the conference for those implementing services in high HIV-burden countries (like Zambia, where access and uptake of COVID-19 vaccination are still very low) is to leverage DSD adaptions to integrate COVID-19 vaccinations and thereby increase vaccination uptake among people living with HIV.
Read the full opinion piece
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DSD in action: Key population-focused HIV service delivery in India during COVID-19
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“We saw that expanded MMD and community distribution of ART during COVID-19 supported people living with HIV to continue their treatment irrespective of their viral load status and access to virtual counselling.” - Subash Ghosh, ACCELERATE
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India’s National AIDS Control Organization (NACO) provides free ART to people living with HIV, including key populations, through public centres.
Before COVID-19, all people living with HIV generally received 30 days of ART, and people considered “stable” on treatment were eligible for multi-month dispensing (MMD).
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We spoke with Subash Ghosh, the Project Lead for ACCELERATE, a PEPFAR- and USAID-supported programme at the Y.R. Gaitonde Center for AIDS Research and Education (YRG CARE), and Rose Pollard, a Program Officer at the Johns Hopkins University School of Medicine, to learn more about HIV service delivery for key populations in India and adaptations made due to COVID-19.
Subash, from your experience at YRG CARE, what are the key lessons learned from COVID-19 adaptations to service delivery, such as MMD and community distribution?
SG: We saw that expanded MMD and community distribution of ART during COVID-19 supported people living with HIV to continue their treatment irrespective of their viral load status and access to virtual counselling. In some cases, people living with HIV were concerned about unintentional disclosure, so they preferred to pick up ART from a convenient location away from their home in coordination with outreach teams at YRG CARE. Many people living with HIV felt that it would be beneficial to maintain MMD and community distribution as these options reduce transportation costs, time taken off work and exposure to COVID-19. For children living with HIV, community distribution of ART and MMD also helped ensure ART adherence through the pandemic and supported favourable treatment outcomes.
Rose, based on your recent assessment of client experiences during COVID-19 presented at IAS 2021, which model did clients from key populations prefer and why?
RP: Key populations in our focus groups appreciated both MMD and home delivery of ART as it made medication accessible and treatment adherence possible without exposing themselves to SARS-CoV-2. However, there were different perspectives about both options. Some individuals had confidentiality concerns about storing more pills at home or having someone show up at home with medications, fearing suspicion from neighbours or family members. Others valued the ease of having refills delivered directly to them at home.
What are the next steps needed to better understand and adapt HIV service delivery to client needs and preferences?
RP: Participants’ varied perspectives necessitate further assessment to understand trends in service preferences among key population groups. Our focus groups also highlighted how key populations want access to services beyond HIV care as the pandemic aggravated many challenges to socioeconomic stability. These include food and nutrition support, mental health counselling and services for other health concerns. Comprehensive models that address health holistically are urgently needed. We are in the process of developing frameworks and implementing comprehensive models that address physical, mental and social well-being for key populations in India.
Read the full interview
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Don't miss
All the latest DSD science from IAS 2021. Download our top picks in our DSD at IAS 2021 summary slides.
Plus, IAS 2021 content is now publicly available. Access all conference content here.
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Get involved
Are you a young investigator working on paediatric and adolescent HIV? Apply to the CIPHER Grant Programme and become the principal investigator on a grant of up to US$150,000 for two years. The submission deadline is 29 October.
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Looking ahead, looking back
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Looking ahead…
- 11-14 October: Check out the programme of the INTEREST conference, to be held virtually, including sessions on service delivery changes due to COVID-19 and treatment optimization.
- 19-22 October: The 52nd Union World Conference on Lung Health will take place virtually with the theme, Lung Health for All: Solutions for a New Era. It includes presentations on quality people-centred TB care. Check out the preliminary programme here.
- 27 October: Join us and register for a webinar to launch the Journal of the International AIDS Society (JIAS) supplement "Differentiated service delivery for HIV during COVID-19: Lessons learned and opportunities".
- 6-11 December: The International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA 2021), taking place as a hybrid in-person (Durban, South Africa) and virtual meeting, is accepting satellite applications until 30 September. Delegates can register at the regular fee until 30 September.
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Looking back…
- In July, the World Health Organization (WHO) launched updated “Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach”. The service delivery chapter emphasizes the need for differentiated approaches for people who are established on ART, such as reduced frequency of clinic visits, use of MMD and implementation of community ART distribution.
- In August, ICAP’s HIV Coverage, Quality, and Impact Network (CQUIN) in collaboration with the South-South HIV Prevention Learning Network (SSLN) held a virtual four-day meeting focused on DSD for key populations. Access meeting resources, presentations and recordings here.
- Watch the recording and view the slides of EpiC’s Decentralized Drug Distribution (DDD) webinar, “DSD ART and the new WHO service delivery guidelines in the context of the COVID-19 pandemic”, which took place in August.
- Watch the recording of the ICAP Grand Rounds webinar, “Differentiated HIV Service Delivery and COVID-19: Resilience, Innovation, and Lessons Learned”, held in July.
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Effects of community-based antiretroviral therapy initiation models on HIV treatment outcomes: A systematic review and meta-analysis, Eshun-Wilson I et al, PLoS Med, May 2021
This systematic review indicates that community ART initiation results in higher ART uptake, retention and viral suppression at 12 months compared with facility-based ART initiation. The results were used to inform the updated WHO guidelines.
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Patient-incurred costs in a differentiated service delivery club intervention compared to standard clinical care in Northwest Tanzania, Okere NE et al, JIAS, June 2021
A cross-sectional study from Tanzania assessed client-incurred costs of a community-based DSD intervention compared with clinic-based care. It found that costs for clients accessing DSD are significantly lower.
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Multimonth dispensing of up to 6 months of antiretroviral therapy in Malawi and Zambia (INTERVAL): a cluster-randomised, non-blinded, non-inferiority trial, Hoffman RM et al, The Lancet Global Health, May 2021
This cluster-randomised, unblinded, non-inferiority trial (INTERVAL) at 30 health facilities in Malawi and Zambia showed that clinical visits with ART dispensing every six months was non-inferior to standard of care and three-monthly ART dispensing.
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A community-based mobile clinic model delivering PrEP for HIV prevention to adolescent girls and young women in Cape Town, South Africa, Rousseau E et al, BMC Health Services Research, August 2021
Through in-depth interviews, this qualitative study explored the feasibility and acceptability of providing PrEP to adolescent girls and young women (aged 16–25 years) via a community-based mobile health clinic.
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Dispensing antiretrovirals during Covid-19 lockdown: re-discovering community-based ART delivery models in Uganda, Zakumumpa H et al, BMC Health Services Research, July 2021
This qualitative case study in Uganda defined five adaptations made to providing antiretroviral therapy during the COVID-19 lockdown, including home-based delivery, extending MMD to six months and leveraging community drug distribution points.
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Evaluation of a community-based HIV test and start program in a conflict affected rural area of Yambio County, South Sudan, Ferreyra C et al, PLoS One, July 2021
Using programmatic data from South Sudan, this retrospective analysis evaluated the feasibility and client outcomes of a pilot community-based HIV testing and ART initiation project in a conflict setting with low ART coverage. Retention in care and virological suppression were comparable with facility-based services and to those in stable contexts.
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Estimating the effect of increasing dispensing intervals on retention in care for people with HIV in Haiti, Parrish C et al, EClinicalMedicine, July 2021
This study analysed routinely collected client data to provide a causal estimate of the relationship between longer ART refills and retention in care in a low-resource setting. Improvements in retention were associated with ART refills of up to four months.
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Watch this interview with Kimberly Green, Global Program Director, Primary Health Care, PATH, about key takeaways from her IAS 2021 presentation, “Differentiated PrEP Delivery – From Pilots to Pushing Towards the Global PrEP targets”, expanding PrEP eligibility criteria and “de-medicalizing” PrEP.
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Do you have something for the next newsletter? We want to hear from you.
Email us at dsd@iasociety.org.
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