Dr Sophie Pascoe, Health Economics and Epidemiology Research Office (HE2RO)

Only a few months ago, I imagined myself enjoying the delights of San Francisco and Oakland at AIDS 2020. Instead, I sat alone, glimpsing the homes and offices of colleagues around the world at the first International AIDS Conference of its kind: AIDS 2020: Virtual. This was a conference that required differentiated delivery to meet the needs of presenters and participants across the globe.

DSD was the focus of around 100 presentations, making it clear that scale up of DSD has continued apace over the past year. Most striking was how DSD models have enabled health system resilience and flexibility in the face of the COVID-19 pandemic, with many countries leveraging these models to support HIV programmes across the cascade. Anna Grimsrud explained that DSD provides the necessary tools to limit exposure to COVID-19 and co-infection among people living with HIV while they continue to access health services. Wilkinson and Preko succinctly summarized the broad categories of DSD expansion and adaptation made by countries in response to COVID-19. 

The development and implementation of peer- and community-led approaches to deliver DSD across the care continuum was the focus of several presentations. Holmes and Singh highlighted the importance of communities being fully involved in the implementation and monitoring of DSD activities. Keder et al described a peer-led approach, including cyber education, for reaching female sex workers in Ethiopia that increased PrEP service uptake during COVID restrictions. Studies in Thailand and Vietnam also demonstrated how peer support groups could become effective service providers.

Ensuring uninterrupted drug supply during lockdown emerged as one of the greatest challenges. Innovative approaches included the TASO Masaka project in Uganda where group leaders reached out to clients telephonically to ensure medication delivery. In Nigeria, temporary drug pick-up centres and peer-led deliveries improved medication pick up. In Zambia, home-based delivery and adherence clubs were as effective as facility-based care. In Haiti, multi-month dispensing (MMD), digital patient tracing and community ART distribution meant that only 2% of patients were lost to follow up during lockdown.

COVID-19 also accelerated the growth of telemedicine and virtual support for DSD models, enabling group DSD models to continue, even in the context of longer refills, with virtual peer support. Evidence for this was a telehealth intervention for new ART initiation in Thailand, telephonic psychosocial support for those struggling with ART in South Africa, and the social media-based #Stayhome#Selftest campaign in Vietnam.

A common theme that emerged was ensuring that the lessons learned from adapting DSD during the COVID-19 pandemic are not lost when it wanes. It is critical that we continue to monitor and evaluate outcomes of clients in DSD models and that we have the health information systems to do this. Biedron et al clearly demonstrated the need for strong data management systems that can track clients decanted from clinics. As Meg Doherty summarized, the COVID-19 challenges have inspired service delivery innovations and we need to make the most of these resilient responses: MMD, community delivery, social media and e-health.


Read Dr Pascoe’s recent publication on perspectives of DSD for HIV treatment in South Africa here