Systematic use of data-driven tools to allocate care services based on needs, including differentiated care for stable individuals and intensive care for those with higher risk, may improve retention and viral suppression in adolescents and young adults living with HIV (AYLHIV).
This cluster randomised trial in western Kenya tested a data-informed stepped care intervention that assigned AYLHIV to four intensities of care according to need. AYLHIV at 12 intervention facilities underwent step assignment at each visit; those at lowest risk were offered differentiated models of service delivery (DSD), and those with risk factors more intensive services. AYLHIV at control sites received standard care. AYLHIV were followed for 12 months. Clinical and viral load data were abstracted from medical records. The primary outcome was the proportion of missed visits (defined as > 30 days late for scheduled visit). Secondary outcomes included loss to follow-up, viral non-suppression and assignment to DSD (multi-month refills or pharmacy fast-track visits). Mixed effects regression was clustered by individual and facility and adjusted for outcomes during the pre-enrolment period and baseline variables that differed by arm.
Between April and July 2022, 1911 AYLHIV ages 10–24 were enrolled (control: 1016, intervention: 895, 1708.8 person-years). Median age was 17, and 1512 (79.5%) were in school. Characteristics were balanced by arm, except for a higher proportion coming to the clinic alone in control arm (68.5% vs. 61.1%, p = 0.04). At intervention facilities, using the DiSC tool, 574 (64.6%) AYLHIV were assigned to DSD, 122 (13.7%) to standard care, 100 (11.3%) to mental health and retention counselling, and 92 (10.4%) to intensive case management. Missed visits were 8.5% in intervention versus 8.3% in control (adjusted risk ratio [aRR]: 1.04, 95% CI: 0.89−1.20); viral non-suppression (7.7% vs. 9.7%, aRR 0.79 95% CI: 0.54−1.16) and antiretroviral therapy adherence (92.8% vs. 94.6%, aRR 0.98 95% CI: 0.94−1.02) were similar between arms. AYLHIV in the intervention arm received more fast-track visits (aRR 1.21, 95% CI: 1.01−1.46). Intervention facilities experienced fewer scheduled appointments compared to control (aRR: 0.95, 95% CI: 0.91−0.98, p = 0.004).
Overall, missed visits and non-suppression were infrequent (< 10%) and did not decrease with the DiSC interventi
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.
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, multi-month dispensing (MMD) and DSD for HIV treatment models. We explored factors associated with DSD implementation using multivariable models.
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.
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 pre-COVID-19 era underline the need for strengthening DSD in HIV care, which remains at the centre of current efforts towards client-centred care.
South Africa has one of the highest incidence rates of notified tuberculosis (TB) in the world. Achieving TB control requires strengthening treatment and support services. The implementation of differentiated delivery models can be used to improve service quality and enhance retention in care. This study aimed to identify treatment and support delivery preferences among people on TB treatment, specifically examining gender differences, to inform the development of differentiated care models for improving engagement and retention in TB treatment services.
A binary, unlabelled, fractional factorial design discrete choice experiment (DCE) was used to investigate preferences for TB treatment adherence support and service delivery. Attributes included who provides the support, how and where support is delivered, medication collection location and frequency of clinic visits. The DCE was administered to individuals who were currently on or recently completed TB treatment, and to those at-risk for being lost-to-care. Data from 284 individuals for the DCE were collected from March to August 2022. Mixed effects logistic regression models were used as primary analysis tools. Latent class analysis (LCA) was used to explore heterogeneity in preference structures.
Compared to standard clinic-based treatment collection, participants preferred collecting their treatment from a mobile community-based location (ß = 0.231; 95% CI: 0.08–0.39), clinic-based fast-tracked pick-ups (ß = 0.539; 95% CI: 0.38–0.70) or home delivery (ß = 0.563; 95% CI: 0.37–0.75). Participants also significantly preferred support offered monthly compared to once-off (ß = 0.167; 95% CI: 0.01–0.32). Furthermore, participants preferred face-to-face support over group (ß = –0.142; 95% CI: –0.27 to –0.02) or phone-based (ß = –0.222; 95% CI: –0.36 to –0.09) support models. LCA revealed three classes with statistically similar preference structures; Class 1 (62%) preferred community-based treatment delivery and support services; Class 2 (28%) preferred clinic-based support and treatment delivery services; and Class 3 (10%), preferred self-selected peer navigator or nurse delivered, and group models of support and prioritised the location of medication pickups, with a preference for any model other than standard clinic collection.
Though preference structures did not differ by gender, respondents revealed strong prefere
Long-term survivors (LTS) of HIV, including individuals diagnosed before the availability of effective antiretroviral therapy (ART), have played a pivotal role in shaping the HIV response. Despite an increase in their number in the United States, their unique medical, social and economic challenges remain underrepresented in HIV policy and research, particularly in the context of HIV cure advancements. While an HIV cure may alleviate ART-related burdens, LTS fear unintended consequences, including the potential loss of critical social benefits, economic support and healthcare access. This study explores the policy priorities of LTS, addressing their current unmet needs and the broader implications of an HIV cure.
We conducted qualitative interviews with 32 LTS across diverse racial, gender and geographic backgrounds, recruited through community-based organizations and research networks from 2023 to 2024. Using inductive thematic analysis, we identified key policy concerns and recommendations based on participants’ lived experiences. Data collection continued until thematic saturation was reached.
LTS emphasized four pressing policy domains: (1) Persistent Healthcare Disparities: Participants reported fragmented Medicare and Medicaid coverage, limited access to essential services (e.g. dental, vision and mental healthcare), and ongoing stigma and discrimination in healthcare settings. (2) Social and Economic Precarity: Housing instability, financial insecurity and employment barriers disproportionately affect LTS, many of whom face systemic barriers to re-entering the workforce. (3) Policy Implications of an HIV Cure: Participants voiced concerns that an HIV cure, while promising, could result in disqualification from disability and social assistance programmes, exacerbating socio-economic vulnerabilities. (4) Structural Reforms for LTS Inclusion: LTS underscored the urgent need for their direct involvement in HIV research, policy development and decision-making to ensure equitable, community-driven solutions.
Policymakers must address comprehensive healthcare access, economic stability and social protections for LTS of HIV. HIV cure research must not undermine existing benefits or widen disparities. Ensuring LTS representation in decision-making is critical to developing equitable policies that safeguard their wellbeing before and after a cure.
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