Experiences and preferences in Zambia and South Africa for delivery of HIV treatment during a clients first six months: a cross-sectional survey

Background: Disengagement from antiretroviral therapy (ART) is highest in the early treatment period (≤6 months after initiation/re-initiation), but low intensity models designed to increase retention generally exclude these clients. We describe client preferences for HIV service delivery in the early treatment period. Methods: From 9/2022-6/2023, we surveyed adult clients who were initiating or on ART for ≤6 months at primary health facilities in South Africa and Zambia. We collected data on experiences with and preferences for HIV treatment. Results: We enrolled 1,098 participants in South Africa (72% female, median age 33) and 771 in Zambia (67% female, median age 32), 38% and 34% of whom were initiating/re-initiating ART in each country, respectively. While clients expressed varied preferences, most participants (94% in South Africa, 87% in Zambia) were not offered choices regarding service delivery. 82% of participants in South Africa and 36% in Zambia reported receiving a 1-month supply of medication at their most recent visit; however, South African participants preferred 2- or 3-month dispensing (69%), while Zambian participants preferred 3-or 6-month dispensing (85%). Many South African participants (65%) would prefer to collect medication in community settings, while Zambian participants (70%) preferred clinic-based collection. Half of participants desired more one-on-one counselling and health information. Most participants reported positive experiences with providers, but long waiting queues were reported by South African participants. Conclusions: During the first six months on ART, many clients would prefer less frequent clinic visits, longer dispensing intervals, and frequent, high-quality counselling. Care models for the early treatment period should reflect these preferences.