Differentiated service delivery, also known as differentiated care, is a client-centred approach that simplifies and adapts HIV services across the cascade to reflect the preferences and expectations of various groups of people living with HIV (PLHIV) while reducing unnecessary burdens on the health system. By providing differentiated service delivery, the health system can reallocate resources to those most in need.
Differentiated service delivery aims to enhance the quality of the client experience. It puts the client at the centre of service delivery. It also ensures the health system functions in both a medically accountable and efficient manner. The central driver to adapting service provision is the client’s needs.
Differentiated service delivery applies across the HIV continuum to all three of the 90-90-90 targets (90% of people living with HIV should know their status; 90% who know their status should be on ART; 90% of those on ART should be virologically suppressed). Differentiated service delivery includes models of care appropriate/suited to testing people unaware of their HIV status to viral suppression of HIV clients enrolled in care.
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Differentiated ART delivery is a component of differentiated service delivery. It aims to improve retention and viral suppression by optimizing models of drug and care delivery. Differentiated ART delivery focuses specifically on clients who are on treatment. This online resource currently places emphasis on differentiated models of ART delivery for stable clients.
Models of differentiated ART delivery can be divided into four categories: health care worker-managed group models; client-managed group models; facility-based individual models; and out-of-facility individual models. In all of these models, clients continue to have clinical consultations as part of their package of care. These models are flexible to accommodate clients who may want or require up referral to the standard of care. Examples from the field of these four types of models can be found here.
Most importantly, differentiated service delivery can improve the quality of care and access to treatment for PLHIV. It can better reach underserved populations and address issues surrounding stigma and discrimination that many PLHIV face when accessing HIV services.
Supporting clients to initiate ART is critical, but it is not enough – retention in care and adherence to effective treatments is required to achieve viral suppression. Data from sites where differentiated ART delivery has been adopted highlight that such interventions can be part of improving retention and adherence and achieving the second and third “90” outlined in the UNAIDS global targets.
Worldwide, 36.7 million people are living with HIV and 17 million people are receiving ART. With the implementation of the WHO 2015 recommendation to “treat all" HIV-positive individuals on ART, health systems, often already under extreme pressure due to lack of human and financial resources, will have to re-examine how ART care is delivered.
Although there are 17 million people on treatment, treatment coverage is still below 50%. Clients who are not currently on treatment need to access ART within a service delivery model that meets their needs and expectations. Further, the health care system must support double the number of ART clients. As highlighted within the most recent WHO guidelines, different packages of care are essential to address these diverse needs. It’s time to deliver differently.
Stable clients are those people living with HIV on ART who are adherent and do not require frequent clinical consultation. However, the definition of a “stable” client has varied across the implemented differentiated models of ART delivery. It is dependent on access to resources, such as routine viral load monitoring.
WHO published a definition of stable clients in the 2016 consolidated guidelines:
“Stable individuals are defined as those who have received ART for at least one year and have no adverse drug reactions that require regular monitoring, no current illnesses or pregnancy, are not currently breastfeeding, have good understanding of lifelong adherence and evidence of treatment success (i.e. two consecutive viral load measurements below 1000 copies/mL). In the absence of viral load monitoring, rising CD4 cell counts or CD4 counts >200 cells/mm3, an objective adherence measure, can be used to indicate treatment success.”
If you are an ART programme manager, facility manager or health care worker, the best model is going to depend on your specific context. It is strongly encouraged that the decision-making process regarding the most appropriate model(s) is based on context, client preferences and selected at the facility level to ensure ownership by both the clients and health care workers.
To be guided through how to select the best model, refer to A Decision Framework for antiretroviral therapy delivery, which explains the 5-step process for building a differentiated model of ART delivery. Additionally, A Decision Framework for ART Delivery for children, adolescents and pregnant and breastfeeding women guides the reader through how to assess the data and identify priorities to address specific and local challenges for these populations.
Differentiated ART delivery should be implemented as a response to specific challenges or barriers faced by clients and where differentiation may serve to improve quality of care, outcomes and client satisfaction. Deciding how to differentiate ART delivery should be based on a local assessment and according to the following three elements:
Click on a pillar area for more information.
In order to maintain quality ART delivery in specific contexts, modifications to how ART is delivered are required. In addition to the consideration of contextual stability, the prevalence of HIV in a given setting will also impact on the specific challenges faced by clients and the appropriateness or extent of specific interventions.
ART delivery should be differentiated based not only on clinical characteristics, but also by considering the challenges of specific populations.
Although this compendium website currently focuses on stable clients, the same concepts and principles from the building blocks can be applied to provide appropriate models of ART delivery for specific populations. Differentiating ART delivery for specific populations can help improve access to HIV care by addressing the structural barriers and adherence issues that specific populations often face.
Each specific population will require a unique and comprehensive package of health care services to overcome particular challenges.
Based on clinical characteristics, clients can be defined as: stable; unstable; and clients with co-morbidities or coinfections. A client can be determined as stable according to WHO’s definition or another definition. Unstable clients may have a high viral load or another characteristic, such as a mental health condition or recently initiated on ART, that classifies them as unstable.
These building blocks are the key components of a service delivery model. The answers to the questions form the building blocks of your service and can be used for whichever element(s) (clinical, specific populations, context) are being considered.
Clinical consultations should be considered separately to ART refill visits. Therefore, for each example, the building blocks are presented for both ART refill visits and clinical consultations.
For more information on the three pillars or building blocks of differentiated ART delivery, click here, or to see how differentiated service delivery models have been built based on the three elements and building block choices, click here.