DSD: Where are we now?

Anna GrimsrudLead Technical AdvisorInternational AIDS Society (IAS)11 November 2019

Differentiated service delivery, or differentiated care, is a client-centered approach that simplifies and

adapts HIV services across the cascade to reflect the preferences and expectations of groups of people

living with HIV (PLHIV) while reducing unnecessary burdens on the health system.

“DSD”=“How people living with HIV who are clinically stable

receive their HIV care, treatment and support”

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What do we know about…

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

Coverage

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What we know about coverage

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

• What we know, we know from CQUIN country dashboards completed by DSD TWGs

• PEPFAR must know…• AMBIT study to provide coverage estimates for Malawi,

South Africa, and Zambia (in 2020)• Last published (Auld et al, 2016, JAIDS) coverage data

from Mozambique, 2004-2013 data

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What we don’t know about coverage

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

• We don’t know about coverage among specific populations• We don’t have good disaggregated data

• By age groups – HUGE gaps/missed opportunities with children and adolescents• For key populations • By gender • For pregnant and breastfeeding women

• We don’t know how best to quantitatively measure coverage from routine data…

• We know there are policy gaps, and gaps between policy and implementation (particularly for children)

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What we need to do better to improve coverage

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

• Ensure DSD funding support• including in PEPFAR COPs and from the Global Fund

• Support community-based and community-led models• What does this mean? Fund community-based organizations and networks of

people living with HIV• This works…

• Africaid Zvandiri and Community Adolescent Treatment Supporters (CATS), Zimbabwe (+Rwanda, Nigeria, Uganda, Namibia)

• TASO, Uganda since 2000s • Community-led monitoring – ITPC’s Community Treatment Observatories in West

and Central Africa• Mosamaria Manguang, South Africa – 25,000 people in Adherence Clubs

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What do we know about …

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

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What we know about qualitySome 2019 evidence

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

• Adherence Clubs in South Africa• National scale-up (Fox et al, PLosMed) - Improved retention,

comparable sustained viral load suppression, retention associates stronger for men than women

• Within PopART SA (Rural Adherence Clubs, Bock et al, JIAS) –reduced LTFU and improved or comparable viral suppression

• External individual pick-up points (CCMDD) in South Africa

• National scale-up (Fox et al, PLosMed) – Reduced retention (may be a data issue), comparable sustained viral load suppression with increased viral suppression among men

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What we know about qualitySome more 2019 evidence

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

• DSD & viral load• Longer time between visits where viral load is available (IeDEA data,

Haas AD et al, JAIDS)• Decentralizing – phlebotomy within CAGs in Zimbabwe (Siwingwa M et

al, BMC Health Serv), training lay people to do DBS in Zambia (Sikombwe et al, PLoS One)

• CAGs in Zimbabwe• “Healthcare workers and clients overwhelmingly perceive CARGs as

beneficial” (Bochner et al, JIAS)

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What we don’t know about quality

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

• Are “fast-track” models actually fast?• How “fast” is “fast”?• Is MMD just the new standard of care?

• Still pulling client files, still having to see a clinician, still having an adherence check/pill count…

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What we need to do better to improve quality

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

• Invest in treatment education and assess quality routinely (poor model implementation ≠ bad model)

• Advocate that DSD is for all people living with HIV

Are health workers reduced to being drug dispensers of antiretroviral treatment? A randomized cross-sectional assessment of the quality of health care for HIV patients in northern Uganda, Ulrike G Seeberger, Joseph J Valadez, Health Policy and Planning, Oct 2019

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What do we know about…

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

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What we need to do better to improve impact

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

• Implement where we do have evidence & policy!• ART refills

• WHO recommendation of 3-6 months, country evidence for 3-months,• Evidence of 6-month refills (Guinea during Ebola, Adherence Clubs South Africa

RCT1,2)• BUT MANY COUNTRIES PROVIDING 1-2 MONTHS

• Clinical consultations • WHO recommendation of 3-6 months, country evidence for 6-months• BUT MANY COUNTRIES STILL MAX 3-MONTHLY• Evidence for annual clinical consultations - SA Adherence Clubs, Zimbabwe

DSD policy (any evidence?)• But also, with viral load every 1-2 years, what’s the rationale/what’s happening

during clinical visits? Is their quality clinical assessment?

• Leverage opportunities – e.g. Global Fund applications

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And what are the key priorities for IAS moving forward?

Funding proposals (and therefore implementation plans) MUST include these programmatic interventions unless good rationale for non-inclusion (e.g. fully funded by another funder)

• Leverage opportunities – e.g. Global Fund applications• Highlight how DSD fits into conversations on UHC• Ensure “needs and expectations” are met, including

psychosocial support and integration of TPT and contraceptive care

• Spotlight and track differentiated ART delivery for clinically stable clients, while also…

• Advocating for DSD for all – including advanced HIV disease, clients initiating ART, clients returning to care

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And what are the key priorities for IAS moving forward?

The CQUIN Project 3rd Annual Meeting | November 10-14, 2019

Diversity of needs of people living with HIV

individuals presenting or returning to care with

advanced HIV disease

individuals presenting or returning to care when

clinically well

individuals who are clinically

stable on ART

Individuals receiving an ART regimen that is failing

Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy, July 2017. Geneva: World Health

Organization; 2017.

“DSD” has focused on this group of people

Differentiated service delivery applies across the HIV care continuum and to all people living with HIV

individuals presenting or returning to care with

advanced HIV disease

individuals presenting or returning to care when

clinically well

individuals who are clinically

stable on ART

Individuals receiving an ART regimen that is failing

UPCOMING EVENTS

Download a full roadmap of DSD satellites, session and posters here

Wednesday, 4 December 07h00-08h30 Differentiated Service Delivery and Advanced HIV

Disease, ICAP at Columbia University07h00-08h30 Differentiated ART delivery approaches for West and

Central Africa: From pilots to plans for scale-up, IAS12h45-14h15 Leveraging differentiated ART delivery models to facilitate

contraceptive care and TPT completion, IAS

Thursday, 05 December 07h00-08h30 Closing the gap on reaching men: Time for action, IAS

Thursday, 20 November10:00 AM – 11:30 AM EST

Child & Adolescent Differentiated HIV Service Delivery, Evidence for Action AIDSFree webinar

EGPAF and WHO Register here today