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We hope that you enjoy the 10th edition of the differentiated service delivery (DSD) newsletter. This newsletter promotes knowledge sharing among stakeholders working on DSD and provides updates on related activities. 
The time is now: Political commitment and financing for differentiated service delivery
Lesley Odendal, Constituency Focal Point, Developing Country NGO Delegation to the Global Fund Board, South Africa
In an unprecedented show of global solidarity and political will, donors at the Global Fund's Sixth Replenishment Conference pledged the largest amount ever raised by any multilateral health organization, as well as by the Global Fund. This will, of course, have significant impact on the HIV response and also on the success of differentiated service delivery.
The Global Fund does not only provide funding for country allocations, but also reserves a portion of the funds for catalytic investments, including strategic initiatives, which are identified as priority areas needed to support the success of country allocations. However, that cannot be funded through country grants alone.
The strategic initiatives include a proposed allocation for DSD to incentivize increased programme quality and efficiency along the HIV testing and treatment cascade. For this to succeed, we will need the political commitment of countries to prioritize client-centred models of HIV service delivery in their grant applications to the Global Fund.
Read more
Mahawa Sylla, independent activist and Humanitarian Affairs Officer at Médecins Sans Frontières (MSF), Guinea

Please tell us about your work and why you decided to pursue a career in the HIV field
My name is Mahawa Sylla and I am an independent HIV community activist and counsellor based in Conakry, Guinea. I also work at MSF as a Humanitarian Affairs Officer. I decided to put HIV at the centre of my activities because, as a person directly affected by HIV, I feel that I must actively participate in improving the quality of life of all people living with HIV. It is important for me to take an active role in HIV-related decision making and ensuring that the voices of people living with HIV are represented. 
Can you tell us more about your work with community organizations and people living with HIV networks?
My main tasks are providing psychosocial support to people living with HIV (face to face and online), supporting the community observatory (including gathering information about the availability of HIV drugs and commodities), providing community-level HIV prevention and testing services, and advocating for quality HIV care. Regarding my role as an HIV activist, I am a founding member of VIE+ (an association of people living with and affected by HIV), established in 2006. VIE+ is a member of REGAP+, the national Guinean Network of Associations of People Living with HIV.
What are the advantages of engaging community organizations and people living with HIV networks in the development and delivery of DSD models?
Through the involvement of people living with HIV networks in the development and delivery of DSD models, we are able to provide a larger range of care and support options, including psychosocial support, to clients seeking care. These models also allow clients to access care closer to home and develop a sense of responsibility for their HIV management.
Read the full interview


Africaid Zvandiri: A differentiated service delivery model for adolescents and young people
Nicola Willis, Africaid, Zimbabwe
Zvandiri is a Zimbabwean model of differentiated service delivery for adolescents and young people living with HIV. In this model, peer-led, community-based and facility-based services are integrated within clinic-based services. These are delivered by trained, mentored young people living with HIV, 18-24 years old, known as community adolescent treatment supporters (CATS). CATS identify adolescents and young people to be linked to HIV testing services and link those testing positive to antiretroviral therapy (ART). The adolescents and young people linked to ART attend clinical visits at three-month intervals. They are then followed up by CATS at home and by SMS for counselling, ART adherence monitoring and identification of “red flags” requiring further investigation or support from the clinic, social welfare or mental health services. CATS co-facilitate support groups, which are integrated within facility-based refill groups and adolescent days, combining psychosocial support, ART refills and viral load monitoring. CATS work with caregivers through home visits, clinics and caregiver workshops.
For additional details on the Zvandiri programme and evidence, see this recent study, policy brief and overview on the PEPFAR solutions platform.

Looking back …
  • ICAP at Columbia University hosted the CQUIN Learning Network’s third annual meeting in Johannesburg, South Africa, on 10-14 November 2019 in collaboration with South Africa’s Department of Health. The meeting brought together more than 200 participants and 14 CQUIN network countries. Find resources from the meeting here.
  • The Elizabeth Glaser Pediatric AIDS Foundation held an Evidence to Action (E2A) webinar in the AIDSFree webinar series on “Child & Adolescent Differentiated HIV Service Delivery” on 20 November. Find the slides and recording here.
  • The DSD initiative of the International AIDS Society (IAS) organized three satellite sessions at ICASA 2019. On Wednesday, 4 December, the early-morning satellite focused on “Differentiated ART delivery approaches for West and Central Africa: From pilots to plans for scale-up”. During the lunchtime satellite, “Leveraging differentiated ART delivery models to facilitate contraceptive care and TPT completion”, the IAS launched a new supplement to its Decision Framework series, entitled “Leveraging Differentiated ART delivery models for stable clients to scale up TB preventive therapy”, available here. The satellite on Thursday, 5 December, focused on “Closing the gap on reaching men: time for action” and presentations of this session will be available here.
Looking ahead …
  • The Draft PEPFAR Country Operational Plan 2020 (COP 20) Guidance is available for public comment until 13 December 2019 and can be accessed here.
  • Get ready for the 23rd International AIDS Conference in San Francisco and Oakland on 6-10 July 2020. Check out the programme preview or organize an official pre-conference or satellite symposium.
Differentiated HIV care in South Africa: the effect of fast-track treatment initiation counselling on ART initiation and viral suppression as partial results of an impact evaluation on the impact of a package of services to improve HIV treatment adherence, Pascoe SJ, Fox MP, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurn N.

This cluster-randomized mixed-methods study evaluated the effect of a package of adherence interventions at 12 intervention sites in South Africa that conducted fast-track treatment initiation counselling (FTIC). It found a 6% increase in ART initiation associated with FTIC, and qualitative data showed that patients and providers perceived FTIC as beneficial.

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Engaging men in HIV programmes: a qualitative study of male engagement in community-based antiretroviral refill groups in Zimbabwe, Mantell JE, Masvawure TB, Mapingure M, Apollo T, Gwanzura C, Block L, Bennett E, Preko P, Musuka G, Rabkin M.
This qualitative study of male engagement in community-based antiretroviral refill groups (CARGs) in Zimbabwe conducted focus group discussions and key informant interviews with service providers, donors and policy makers. Despite perceived advantages of CARGs, such as mutual psychosocial support and convenience, concerns about stigma and privacy were perceived to be the primary reason for men's non-participation.
Read more 
Accurate dried blood spots collection in the community using non-medically trained personnel could support scaling up routine viral load testing in resource limited settings, Sikombe K, Hantuba C, Musukuma K, Sharma A, Padian N, Holmes C, Czaicki N, Simbeza S, Somwe P, Bolton-Moore C, Sikazwe I, Geng E.
This is an assessment of dried blood spots (DBS) collection through non-medically trained personnel (NMP) to capture viral load results from people living with HIV outside clinic settings in rural and urban districts in Zambia. While DBS viral load collection by NMP is feasible in Zambia, the authors advocate for further research comparing the approach with collection through medically skilled personal.
Read more
Perceptions of Community and Clinic-Based Adherence Clubs for Patients Stable on Antiretroviral Treatment: A Mixed Methods Study, Mudavanhu M, West NS, Schwartz SR, Mutunga L, Keyser V, Bassett J, Van Rie A, Hanrahan CF.

This mixed-methods study, set within a randomized controlled trial of community versus clinic-based adherence clubs for retention in care in South Africa, found that participants in both arms favourably rated adherence clubs. 
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Adaptive Viral Load Monitoring Frequency to Facilitate Differentiated Care: A Modeling Study From Rakai, Uganda, Ssempijja V, Nason M, Nakigozi G, Ndyanabo A, Gray R, Wawer M, Chang LW, Gabriel E, Quinn TC, Serwadda D, Reynolds SJ.
This modelling study from Uganda investigated whether viral load monitoring frequency could be reduced while maintaining detection of treatment failure. It found that monitoring every six months had the fewest months of undetected failure, but also had the highest number of viral load tests compared with the other six monitoring schemes tested.
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The rollout of Community ART Refill Groups in Zimbabwe: a qualitative evaluation, Bochner AF, Meacham E, Mhungu N, Manyanga P, Petracca F, Muserere C, Gonese G, Makunike B, Wazara B, Gwanzura C, Nyika P, Levine R, Mutasa-Apollo T, Balachandra S, Wiktor SZ.
This qualitative evaluation of community ART refill groups (CARGs) conducted focus group discussions in 10 clinics in Zimbabwe. Healthcare workers and clients overwhelmingly perceive CARGs as beneficial, and the authors argue that the CARG model can be successfully implemented at national scale.
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Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa, Bock P, Gunst C, Maschilla L, Holtman R, Grobbelaar N, Wademan D, Dunbar R, Fatti G, Kruger J, Ford N, Hoddinott G.
This study combines a retrospective cohort analysis of routine data and a descriptive analysis of survey data to determine client health outcomes in community-based adherence clubs and perceptions of factors key to the successful implementation of these clubs. It found good clinical outcomes and positive client and healthcare worker perception of clubs.
Read more

Peter Sands on what the Global Fund brings to the UHC debate
During the United Nations General Assembly in September 2019, Global Fund Executive Director Peter Sands spoke to Devex about the organization's role in the context of the push for universal health coverage (UHC).
Watch the video

Out-of-facility community ART distribution: A toolkit by MSF
In 2018, MSF started piloting an out-of-facility community ART distribution model, also called OFCAD, in Masvingo Province in Zimbabwe, in collaboration with the Ministry of Health and Childcare Zimbabwe. Based on lessons learned from this pilot, MSF developed a toolkit on how to make antiretroviral treatment more accessible for remote populations, outlining a step-by-step approach to implementing the OFCAD model.

Check out the toolkit

AIDS 2020 Abstract Mentor Programme – Sign up to become a mentor or submit your abstract for mentorship
The Abstract Mentor Programme (AMP) supports less experienced researchers in improving their abstracts before submitting them to International AIDS Conferences to increase the chance of their work being accepted for the programme. The AMP specifically targets researchers from resource-limited settings to provide an opportunity for rigorous mentoring in research and writing.

Submit your abstract for mentorship before 19 December 2019 or sign up as mentor here.

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Photo credits in order of appearance: 
(1) The Global Fund/Alexia Webster, (2) IAS/Cyril Otabil, (3) Africaid Zvandiri, (4) IAS/Luqman Mahoro, (5) Devex
Copyright © 2019 International AIDS Society, All rights reserved.

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