Differentiated service delivery in HIV care and treatment An exploration of sustainability and impact from patients' and providers' perspectives

The immediate initiation of antiretroviral treatment following a positive HIV diagnosis is currently recommended by WHO. To facilitate implementation, the global fast track target to end the AIDS epidemic by 2030 was set and aims that 95% of HIV positive people know their status, of those, that 95% are placed on antiretroviral treatment (ART) and of those on ART that 95% are virally suppressed. Differentiating HIV services according to patients’ status and preferences while considering health system constraints appears a promising strategy for achieving global targets especially in low- and middle-income countries. The successful implementation of differentiated service delivery (DSD) approaches is however required to achieve global targets and therefore warrants an investigation into their sustainability and how they impact patients. This thesis employed a multi-disciplinary implementation research design to elucidate the sustainability of DSD as well as the impact of a DSD ART club model from a patients’ perspective highlighting the progress made and opportunities for further improvement. Specifically, the research queried the impact of DSD on quality of life, quality of care, and patient costs. The sustainability of various DSD approaches as well as barriers faced by patients as they navigate the health system were also investigated. DSD was considered potentially sustainable, showed significant cost reduction for stable patients, and comparable quality of life and quality of care compared to standard clinic-based service delivery.