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Welcome to the first differentiated service delivery (DSD) newsletter of 2021. This newsletter focuses on DSD of HIV treatment and cost effectiveness with recent evidence from sub-Saharan Africa, spotlights DSD in Uganda and shares the latest DSD news, publications and upcoming webinars.

Do DSD models for HIV treatment save money?
Sydney Rosen, Research Professor at Boston University and Co-Director of HE2RO, writes:

Among other anticipated benefits, DSD models for HIV treatment are expected to reduce the cost of service delivery to both the health system and the patient, especially for the large number of stable patients in most national antiretroviral therapy (ART) programmes. This expectation follows logically from the notion that most DSD models are designed to be “less intensive” than conventional care and, therefore, presumably utilize fewer resources per patient served. Until recently, though, little empirical evidence on DSD model costs was available.

Weighing up costs

Now, several newly published studies estimate the costs of DSD models implemented routinely (that is, not as pilot or demonstration projects or studies), allowing us to compare the true costs and outcomes of DSD with conventional, facility-based care in different countries in sub-Saharan Africa: Lesotho, Malawi, South Africa, Uganda, Zambia and Zimbabwe.

6MMD consistently less expensive

In general, the cost differences between models per patient were modest, mainly reflecting the large share of costs attributable to antiretroviral medications, whose cost does not vary with model of care. Models that incorporated six-month medication dispensing (6MMD) were consistently less expensive than conventional care.

What it means for patients

More striking than the cost implications to health systems were the sharp falls in costs to patients themselves. In studies that surveyed patients about the costs they incurred for obtaining treatment, including transport fares and the value of the time spent, patients reported cutting their own out-of-pocket and/or opportunity cost expenditures by between a quarter and a half per year, generally due to the reduced number of full clinic visits required by DSD models. Some models, such as adherence clubs, did not reduce time costs substantially, but did save patients money for transport.

Read the full opinion piece
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Faces of DSD

“In Uganda, models like community drug distribution points have proven to be more cost effective than the facility-based DSD models.” 

Dr Josen Kiggundu, Ministry of Health Uganda 
Dr Josen Kiggundu is the Senior Program Officer for DSD at the Ministry AIDS Control Program, Ministry of Health Uganda

Dr Kiggundu, what are the main cost drivers in the provision of HIV treatment and care in Uganda?

Antiretrovirals (ARVs) and laboratory tests are the most expensive components of any HIV treatment and care programme – and these costs remain largely the same regardless of the DSD model in which they are provided. Costs of non-ARV medicines and human resources are lower in the less intensive DSD models than the intensive DSD models.

Which models do clients prefer from both a cost and quality perspective?

We have seen large numbers of recipients of care in the fast-track model, likely because it offers many benefits. With fast-track, there’s less waiting time at the facility, people can receive ARVs for three or six months and they can access healthcare workers as required.

Community-based DSD models for HIV treatment have been widely implemented in Uganda. What can you share regarding cost effectiveness of these models?

Models like community drug distribution points (CDDPs) and community client-led ART delivery (CCLADs) have proven to be more cost effective than the facility-based DSD models. These models reduce costs for recipients of care as transport costs are reduced. However, the CDDP model is associated with more costs than other community models because CDDPs are facilitated by healthcare workers. Taking services closer to the homes of recipients of care leads to increased costs for healthcare workers’ transport and allowances.

Read the full interview here.

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DSD in action

Same-day ART initiation hub during COVID-19: Telehealth options and courier delivery

Phanuphak N, Ramautarsing R, Amatavete S, Lujintanon S, Hanaree C, Prabjuntuek C, Sripanjakun J, Peelay J, Termvanich K, Uttayananon J, Institute of HIV Research and Innovation, Bangkok, Thailand

Since July 2017, the Institute of HIV Research and Innovation (IHRI) in Bangkok, Thailand, has been managing a same-day ART initiation service in which ART-naïve clients start therapy on the same day of HIV diagnosis at a testing centre. A team of peer navigators provides ongoing counselling and psychosocial support and facilitates referral to a long-term ART maintenance facility. Clients attend two clinical visits (for ART initiation and follow up) and receive a 10-week supply of ART.

During the COVID-19 lockdown in March 2020, a telehealth option for follow-up visits, with clinical consultation through video call, was incorporated into the same-day ART service. A four-week ART supply was provided to clinically eligible clients on the day of HIV diagnosis and a follow-up visit was scheduled two weeks later. This visit could be conducted in person at the clinic or virtually if the client preferred. Clients who presented with severe adverse events were required to come back to the facility for pharmacological management; those who tolerated ART well would receive another six-week supply of ART via courier to ensure therapy continuation during the transition to the long-term ART maintenance facility.

There was high client acceptability of virtual follow up and an increased rate of follow-up visits that were successfully completed without severe adverse events. Moreover, telehealth reduced costs for clients by eliminating travel costs and limiting loss of income and time.

Discover other examples of HIV service delivery adaptations due to Covid-19.
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Looking ahead, looking back
Looking ahead…
Looking back …
What we're reading

Twentyfourmonth outcomes from a clusterrandomized controlled trial of extending antiretroviral therapy refills in ART adherence clubs, Cassidy T et al, JIAS, Dec 2020.    

This trial randomized community‐based and facility‐based adherence clubs (ACs) to standard of care (SoC) or intervention ACs. After 24 months, intervention AC clients receiving six‐month ART refills showed non‐inferior retention in care, viral load completion and viral load suppression compared with those in SoC ACs.

Retention in care and viral suppression in differentiated service delivery models for HIV treatment delivery in subSaharan Africa: a rapid systematic review, Long L et al, JIAS, Nov 2020.

This rapid systematic review of peer‐reviewed publications reporting outcomes of DSD for HIV treatment in sub‐Saharan Africa describes what is known about clinical outcomes. It suggests that retention in care and viral suppression among those in DSD models are roughly equivalent to those in conventional models of care.

Adapting HIV services for pregnant and breastfeeding women, infants, children, adolescents and families in resourceconstrained settings during the COVID19 pandemic, Vrazo AC et al, JIAS, Sept 2020.
This commentary calls for whole‐family programme adaptations along the HIV clinical continuum to ensure the continuity of life‐saving HIV case identification and treatment efforts during the COVID-19 pandemic.

Improved Viral Suppression With Streamlined Care in the SEARCH Study, Hickey MD et al, JAIDS, Dec 2020.

This analysis uses data from the SEARCH universal test and treat trial in rural Kenya and Uganda to evaluate the effect of a streamlined DSD model on viral suppression.    

Community-based antiretroviral therapy versus standard clinic-based services for HIV in South Africa and Uganda (DO ART): a randomised trial, Barnabas RV et al, Lancet Glob Health, Oct 2020.  
This household-randomized, unblinded trial (DO-ART study) tested the effect of community-based ART delivery versus clinic delivery on viral suppression among people living with HIV not on ART. Community-based ART was considered safe, with few adverse events reported.

The where, when, and how of community-based versus clinic-based ART delivery in South Africa and Uganda, Nachega JB et al, Lancet Glob Health, Oct 2020.    

This comment highlights the public health implications of the results of the Delivery Optimization of Antiretroviral Therapy (DO-ART) study (see above) and the role of implementation research in the HIV response.

What we're watching

Discover the Collect & Go Smart Lockers for chronic care medicine dispensing and find out more about how BonoloMeds in Lesotho uses them.

Don't miss
Why community-led HIV responses need increased support in West and Central Africa

Read this call for commitments published by Médecins Sans Frontières and 25 other community and civil society organizations ahead of the UNAIDS PCB meeting in December 2020.
Get involved
Job opening: CQUIN Project Clinical Advisor, Eastern & Southern Africa

ICAP at Columbia University’s CQUIN project for DSD is looking for a Clinical Advisor to be based in Eswatini, Zimbabwe, Kenya or other country in East/southern Africa. Find out more.
Get in touch
Do you have something for the next newsletter? We want to hear from you.
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Photo credits in order of appearance:
(1) Eric Bond/EGPAF (2) Dr Josen Kiggundu (3) IHRI Thailand (4) Collect&Go Smart Lockers
Copyright © 2021 International AIDS Society, All rights reserved.

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