Global Guidance

The World Health Organization (WHO)

The WHO provides guidelines, recommendations and key considerations to support differentiated service delivery across the HIV care continuum.

In March 2021, the WHO released Updated recommendations on service delivery for the treatment and care of people living with HIV and Updated recommendations on HIV prevention, infant diagnosis, antiretroviral initiation and monitoring. These new recommendations are an update to the 2016 WHO Consolidated Guidelines on the use of ARV drugs for treating and preventing HIV infection (see below). WHO now recommends that people on antiretroviral therapy (ART) for at least 6 months and responding well, should be offered clinical visits every 3 to 6 months, preferably every 6 months, and should be offered refills of ART lasting 3 to 6 months, preferably 6 months.

In June 2020, WHO published Maintaining essential health services: operational guidance for the COVID-19 context. On page 39-42, specific modifications for HIV service delivery in periods of COVID-19 related disruption are detailed, along with recommendations for transition towards restoration of activities as restrictions are relaxed.

In March 2020, WHO released the WHO operational handbook on tuberculosis. Module 1: Prevention. Tuberculosis preventive treatment, an implementation guide for the simultaneously released updated tuberculosis (TB) guidelines. The operational handbook recommends integrating intensified TB case finding and TB preventive therapy (TPT) within differentiated antiretroviral therapy delivery models. Client visits should be scheduled such that they can pick up antiretrovirals and TPT drugs at the same time.

In December 2019, WHO published a technical brief to define and clarify the key elements of adolescent-friendly health services, summarize existing guidance on adolescent-friendly health services and differentiated service delivery for adolescents living with HIV while showcasing best-practice case studies based on country experience in implementing these services.

In 2018, the HIV self-testing strategic framework: a guide for planning, introducing and scaling up was released to support uptake of HIV self-testing including the six-step approach to differentiated HIV testing. In July 2017, WHO prequalified the first HIV self-test. WHO has recommended HIV self-testing since November 2016 when they released a supplement guideline on HIV self-testing and partner notification. This supplement was to the 2015 Consolidated guidelines on HIV testing services.  

The 2017 Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy also includes differentiated service delivery. This guideline adds recommendations for appropriate packages of care for clients presenting or returning to care with either advanced HIV disease or when clinically well.

The 2017 Key considerations for differentiated antiretroviral therapy delivery for specific populations: children, adolescents, pregnant and breastfeeding women and key populations outlines the rationale for and features of differentiated ART delivery for clinically stable clients in these populations. The document complements A Decision Framework for differentiated antiretroviral therapy delivery for children, adolescents and pregnant and breastfeeding women (see, DSD decision frameworks).

WHO first recommended a differentiated care approach in the 2016 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection, Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations and Consolidated guidelines on person-centred HIV patient monitoring and case surveillance were published in the same year.

 

The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)

GFATM released a toolkit in November 2015 to provide operational guidance to managers of health facilities on implementing differentiated care approaches. GFATM also released their HIV Information Note in July 2019 to provide guidance to applicants developing Global Fund funding requests for the 2020-2022 funding cycle. Differentiated service delivery is highlighted as a key approach for HIV programmes to enhance implementation quality and efficiency. 

The Joint United Nations Programme on HIV/AIDS (UNAIDS)

The newest UNAIDS report, COVID-19 and HIV: 1 moment, 2 epidemics, 3 opportunities, looks at how lessons learnt in the fight against HIV can be leveraged to guide the COVID-19 response.  DSD is highlighted as a strategy for enabling “precision public health”, which can better meet the needs of diverse individuals and communities.

The UNAIDS Global AIDS report 2020 highlights progress towards our 2020 targets and the risks that COVID-19 poses to HIV progress. It also highlights the role of differentiated service delivery – including extending ART refills, supporting community-based approaches and ensuring peer-support for people living with HIV.

The 2019 Global AIDS Update from UNAIDS, Communities at the centre. Defending rights, breaking barriers, reaching people with HIV services, recognizes that an increasing number of countries are using differentiated service delivery models to establish community-based systems for providing services across the cascade and making the 90-90-90 targets a reality.

In 2015, UNAIDS partnered with Medécins Sans Frontières (MSF) to release the first in a series of case studies highlighting the need to adapt ART delivery systems to meaningfully include community-based services. 

The United States President’s Emergency Plan for AIDS Relief (PEPFAR)

The PEPFAR 2021 Country and Regional Operational Plan Guidance for all PEPFAR countries highlights differentiated service delivery for HIV treatment as a minimum programme requirement for all countries supported by PEPFAR (pg. 48). The guidance further describes all four DSD for HIV treatment models including healthcare worker-managed groups, client-managed groups, facility-based groups and out-of-facility individual models. PEPFAR outlines the separation between clinical services and drug delivery. Throughout the guidance, PEPFAR emphasizes multi-month dispensing and decentralized drug delivery. All populations – including children, adolescents, pregnant and breastfeeding women, and members of key populations – are supported to receive DSD for HIV treatment. 

USAID's Supply Chain for Health team has put together an antiretroviral (ARV) planning tool to help countries consider their ARV procurement and supply chain planning for implementing i. “treat all” and ii. longer ART refills, also known as multi-month scripting (MMS).

Medécins Sans Frontières (MSF)

MSF released its first report, Closer to Home, in 2012 (updated version in 2013) on community-based models of ART delivery that it had been piloting for stable clients in sub-Saharan African countries in partnership with country health authorities. Lessons from implementation in Malawi are summarized in the 2015 report Lessons learnt from implementing CAGs in Thyolo, Malawi

Guidance on how to implement models of differentiated ART delivery are also available from MSF in the Resource Library, including a toolkit for client-managed groups known as Community ART Groups in English and French, a report and toolkit for health care worker managed groups known as Adherence Clubs as well as for Family Clubs and for an out-of-facility model, or PODI, available in English and French. 

Up the care cascade, a report and toolkit on ART/TB/PMTCT initiation patient education and counselling from the MSF Khayelitsha project is available for download below.