Effectiveness and experiences with differentiated service delivery of HIV care in Kisumu County, Kenya: A mixed methods study, 2014–2021

Abstract

The adoption of the test and treat policy by the World Health Organization (WHO) in 2015 led to an unprecedented increase in the number of people living with HIV (PLHIV) enrolling into HIV treatment, thereby increasing the burden on HIV service delivery. To compensate, WHO endorsed the Differentiated Service Delivery (DSD) approach to reduce the burden on the health care system and therefore support attainment of the UNAIDS 95-95-95 goals by 2030. This study examined clinical outcomes among clients enrolled in the DSD models and examined health care worker and client experiences of the DSD approach. A client-level pre-post study was conducted in 14 Ministry of Health (MOH) facilities in Kisumu County from October 2014 – March 2021 to examine retention and viral load suppression (<1000 copies/mL) in a cohort of stable clients aged 20 years and above at three time points: immediately preceding DSD start (pre-DSD; 2014–2016), 12 months post-DSD implementation (midline), and 24 months post-DSD (endline). Focus group discussions (FGDs) were conducted to assess DSD experiences among a sample of adult clients and health care workers. Findings from the pre-post analysis showed a significant increase in retention at 12 months (99.2%) and 24 months (98.9%) compared to pre-DSD (86.4%; p < 0.001). The predominant themes shared by clients and healthcare workers in FGDs were high satisfaction with DSD due to the efficiency of services, improved staff attitudes, and reduced clinic workload. Clients also expressed a strong preference for facility-based models owing to perceived stigma and privacy concerns associated with community DSD models. This study provides important insights on the promising effectiveness of DSD models on sustained retention on ART and viral suppression and the acceptability of this modality for client-centered HIV care. Background HIV care and treatment has undergone major changes in recent years with the dual roll out of universal test and treat for everyone living with HIV and differentiated service delivery (DSD) models. The test and treat approach recommended by World Health Organization (WHO) has escalated the number of people living with HIV (PLHIV) receiving antiretroviral treatment (ART) [1–4], with ART coverage for PLHIV increasing globally from 46% in 2015 to 77% in 2023 [5,6]. The adoption of the test and treat policy also increased the burden of HIV service delivery to already constrained health facilities, worsening clinic congestion, including in Kenya where the test and treat policy rolled-out in 2016 [7–12]. In response to the increasing number of PLHIV on ART, WHO endorsed DSD to reduce the health care burden through a simplified, client-centered approach across the HIV cascade. DSD was also developed to accelerate attainment of HIV epidemic control, hence facilitating achievement of the Joint United Nations Programme on AIDS (UNAIDS) 95-95-95 goals by 2030 [13].

With the roll-out of DSD, it is essential to ensure that quality services are delivered effectively and efficiently to sustain or improve clinical outcomes including retention in HIV care and viral load suppression. Poor retention in HIV care and treatment programs has been identified as the most common reason for treatment failure among PLHIV on ART [14,15]. In Kenya, retention in care is estimated to have dropped to 69% by 36 months following ART initiation among adults [16,17]. Retention in care is tied to viral suppression and is central to attainment of UNAIDS 95-95-95 goals for epidemic control through reduction in community viral load [5,12,13,18]. Several studies in sub-Saharan Africa have reported comparable effectiveness of DSD models to standard facility-based care in sustaining high retention rates in HIV care and viral suppression [19–21]. However, there are variations in study designs, DSD models evaluated, populations, and outcome measurements.

Kenya adopted the test and treat strategy in 2016 and initiated the roll-out of DSD approaches in early 2017 [12,22,23]. In Kenya, DSD models have been evaluated in the context of continuation of services during the COVID-19 pandemic [24], as well as client preferences and factors associated with enrollment into different DSD models [25,26]. Yet, there is a need to examine the effects of DSD implementation on clinical outcomes in the Kenyan context.

Family AIDS Care & Education Services (FACES), a U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)/ U.S. Center for Disease Control (U.S. CDC) implementing partner, supported the Kisumu County Ministry of Health (MOH) to implement its DSD model in Kisumu County, Kenya. This study examined the effectiveness of DSD approaches at improving and maintaining client retention and clinical health outcomes, including viral suppression, and explored client and health care worker experiences with DSD.