Barriers and facilitators to the implementation and scale up of differentiated service delivery models for HIV treatment in Africa: a scoping review

(2022) 22:1431 Belay et al. BMC Health Services Research https://doi.org/10.1186/s12913-022-08825-2 RESEARCH ARTICLE Open Access Barriers and facilitators to the implementation and scale up of differentiated service delivery models for HIV treatment in Africa: a scoping review Yihalem Abebe Belay1,2* , Mezgebu Yitayal2, Asmamaw Atnafu2 and Fitalew Agimass Taye3 Abstract Background: In the face of health-system constraints, local policymakers and decision-makers face difficult choices about how to implement, expand and institutionalize antiretroviral therapy (ART) services. This scoping review aimed to describe the barriers and facilitators to the implementation and scale up of differentiated service delivery (DSD) models for HIV treatment in Africa. Methods: PubMed, Web of Science, Embase, Scopus, CINAHL, Global Health, Google, and Google Scholar databases were searched. There was no start date thereby all references up until May 12, 2021, were included in this review. We included studies reported in the English language focusing on stable adult people living with human immune deficiency virus (HIV) on ART and the healthcare providers in Africa. Studies related to children, adolescents, pregnant and lactating women, and key populations (people who inject drugs, men having sex with men, transgender persons, sex workers, and prisoners), and studies about effectiveness, cost, cost-effectiveness, and pre or post-exposure prophylaxis were excluded. A descriptive analysis was done. Results: Fifty-seven articles fulfilled our eligibility criteria. Several factors influencing DSD implementation and scaleup emerged. There is variability in the reported factors across DSD models and studies, with the same element serving as a facilitator in one context but a barrier in another. Perceived reduction in costs of visit for patients, reduction in staff workload and overburdening of health facilities, and improved or maintained patients’ adherence and retention were reported facilitators for implementing DSD models. Patients’ fear of stigma and discrimination, patients’ and providers’ low literacy levels on the DSD model, ARV drug stock-outs, and supply chain inconsistencies were major barriers affecting DSD model implementation. Stigma, lack of model adoption from providers, and a lack of resources were reported as a bottleneck for the DSD model scale up. Leadership and governance were reported as both a facilitator and a barrier to scaling up the DSD model. Conclusions: This review has important implications for policy, practice, and research as it increases understanding of the factors that influence DSD model implementation and scale up. Large-scale studies based on implementation and scale up theories, models, and frameworks focusing on each DSD model in each healthcare setting are needed. *Correspondence: 2 Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Belay et al. BMC Health Services Research (2022) 22:1431 Page 2 of 23 Keywords: Differentiated service delivery, Implementation, Scale up, ART, Africa, Review Background Africa bears the highest global human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) burden, with over two-thirds of all HIV-positive people (25.7 million) residing in this developing region with severe gaps in access to HIV services (prevention, diagnosis, treatment, and care) [1]. The Joint United Nations Programme on HIV/AIDS (UNAIDS) set 90–90–90 goals for 2020 in response to the HIV epidemic, aiming to ensure that 90% of all individuals living with HIV know their HIV status, 90% of all persons with confirmed HIV infection receive sustained ART, and 90% of all people getting ART have viral suppression. A new 95-95-95 target has been set for 2030 [2]. To achieve the 90-90-90 goals, the World Health Organization (WHO) released ART guidelines recommending a “treat-all” approach, whereby all HIV-positive populations and age groups are eligible for ART [3]. In 2015, the WHO recommended differentiated models of care, emphasizing the need to strengthen the continuum of HIV care and improve service quality and access, adherence and retention, clinical outcomes, efficiency, and cost of services, particularly in high-prevalence countries [3, 4]. The differentiated HIV treatment for clinically stable patients is a component of DSD models for HIV which focus on the second and third 90-90-90 targets [5]. Differentiated HIV treatment models aim to put people at the center of antiretroviral delivery and are characterized by four components: i) types of services delivered; (ii) location of service delivery; (iii) provider of health services; and (iv) frequency of health services [4, 5]. The DSD models for HIV treatment can be described within four categories. In healthcare worker-managed groups, clients receive their ART refills in a group and either a professional or a lay healthcare staff member manages this group. The groups meet within and/or outside of healthcare facilities. In client-managed group models, clients receive their ART refills in a group in which clients meet outside of health care facilities and manage and run the refills themselves. In facility-based individual models, ART refill visits are separated from clinical consultations. When clients have an ART refill visit, they bypass any clinical staff or adherence support and proceed directly to receive their medication. For outof-facility individual models, ART refills and, in some cases, clinical consultations are provided to individuals outside of healthcare facilities, for example, community pharmacies, outreach models, and home delivery [6]. To achieve the promise of DSD, model adoption, implementation, scale-up, and evaluation are (...truncated)