The Differentiated Service Delivery Approach

Differentiated service delivery is a patient-centered approach to HIV prevention, care, and treatment. Moving away from a “one size fits all” model, the strategy tailors HIV services for diverse groups of people living with HIV while maintaining the principles of the public health approach.

With differentiated care, stable patients may receive key services in a community setting rather than in health facilities, enabling them to make less frequent visits to clinics and pharmacies. In addition to streamlining their care and making it more convenient, this approach allows health workers to spend more time with less stable patients and those with advanced disease, increasing efficiency and improving quality of care. Services can be tailored for other groups with diverse needs, such as adolescents and young people, pregnant and breast-feeding women, mobile and migrant populations, and others.

Why Differentiated Service Delivery?

Changing global guidelines and ambitious treatment targets have markedly increased the number of people eligible for antiretroviral therapy (ART). To galvanize efforts toward ending the HIV epidemic, the United Nations and its partners have committed to the 90–90–90 targets to identify 90 percent of individuals with HIV, initiate 90 percent of those diagnosed on ART for 90 percent of those diagnosed, and maintain viral suppression in 90 percent of those on ART. To meet this target, the number of people on ART will need to double by 2020.

The Treatment Target | Original Source: UNAIDS

The Treatment Target | Original Source: UNAIDS

Achieving these targets will not be easy. Global funding for HIV has plateaued, and many countries are being asked to do more with less when it comes to HIV programming. A second challenge is that the growing numbers of patients on ART have led to overcrowding at health facilities, increasing wait times for patients, overwhelming clinicians, and consequently compromising patient satisfaction. Finally, gaps in program quality, such as suboptimal retention rates, threaten both individual patient outcomes and public health goals.

Differentiated service delivery is a practical approach to addressing these challenges. It varies the design and delivery of services offered to different groups of patients and aims to enhance quality, efficiency, and patient satisfaction. The goal is to place the client at the center of service delivery while maximizing health system efficiency. Key elements of this approach include re-assessing the “when, where, who, and what” of HIV services for patient groups with different clinical, psychosocial, and contextual characteristics.

The World Health Organization (WHO), the President’s Emergency Plan for AIDS Relief (PEPFAR), and an increasing number of national Ministries of Health have endorsed the differentiated service delivery strategy.

Original Source: ICAP

How it Works

In the past, many HIV treatment guidelines in low-resource settings recommended a standardized treatment strategy for most adults. In response to the growing number and diversity of people on ART, differentiated care models have been designed to respond to different needs, contexts, and subpopulations.

In its decision framework, the International AIDS Society (IAS) characterizes these building blocks as the “when, where, who, and what”of service delivery.

Original Source: 2016 WHO guidelines, IAS, Differentiatedcare.org

Original Source: 2016 WHO guidelines, IAS, Differentiatedcare.org

Examples of Differentiated Service Delivery

Stable Patients

In the early days of HIV program scale-up, many people living with HIV receiving treatment had advanced disease. Treatment protocols were intensive, requiring monthly clinic visits and frequent assessment of clinical status and adherence to treatment. Program implementers recognized this model as unnecessary, inconvenient, and resource-intensive for patients doing well on ART who were stably treated for years. A range of alternatives were developed, including:

  • Visit spacing and multi-month ART dispensing
  • Fast-track appointments
  • Clinic-based ART clubs
  • Community-based ART dispensing
  • Community ART distribution points

Examples and resources on differentiated models for stable patients can been found on the CQUIN resources page and at www.differentiatedcare.org.

Unstable Patients

The evidence base for differentiated care for stable patients has grown recently. Innovative pilot programs have explored approaches like fast-track appointments, multi-month ART prescribing, decreased visit frequency, clinic-based ART clubs, and community-based ART groups. Less attention has been paid to developing differentiated models of care for patients with advanced or unstable HIV disease. CQUIN is spearheading a review of differentiated care for unstable patients, identifying several pilot projects:

  • In Kenya, ICAP and the Ministry of Health have developed an approach called the Severely Immunocompromised Package of Care (SIPOC), which includes standard operating protocols, checklists, and other job aides designed to support delivery of a defined set of staging, prophylaxis, and ART services. The charts of patients with CD4 cell counts less than 100 cells/mm3 are flagged with a SIPOC sticker, and a SIPOC patient assessment form is added to each chart. Health workers are trained to be vigilant in identifying and managing high-risk patients, and facility-level supplies and equipment are defined in advance.
  • In Malawi, the Lighthouse Trust is piloting a differentiated package of care for Advanced, Late, and Unstable Patients (ALUP). This will include intensified screening for opportunistic infections, enhanced prophylaxis, and nutritional supplementation.

Adolescents and Young People

In Kenya, ICAP worked with the Ministry of Health to develop a differentiated care package for HIV-infected school-going youth (aged 10-24 years) at 116 health facilities. The objectives were to:

  1. Deliver the Kenya National Adolescent Package of Care (APOC)
  2. Reduce missed appointments
  3. Address knowledge gaps among adolescents and youth
  4. Provide peer-to-peer support
  5. Build health worker capacity
  6. Restructure the health system to be more responsive to needs of adolescents and youth

Examples of differentiated services included:

  • Dedicated clinic days: three monthly adolescent clinics, one for 10-14-year-olds, one for 15-19-year-olds, and one for 20-24-year-olds.
  • Multi-month prescribing: Adolescents received a larger ART supply at each visit, enabling them to ensure they had medicines during the school semester.
  • Adolescent peer educators and champions: Adolescents were trained to deliver health talks to their peers, and to support retention in care by tracking those who missed appointments.

Early results show the intervention reduced missed appointments and increased retention in care among adolescents.

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