Differentiated Screening and HIV Testing
Out-of-facility testing allows for specific high-risk or hard and far-to-reach population groups who would not have visited the facilities to receive HIV testing services. We observed that facilities performing out-of-facility testing used either a focused or an integrated approach. Focused out-of-facility testing brings coverage to underserved populations or specific geographical areas. In the AIDS Support Organization (TASO), Uganda, each TASO site targeted different key populations such as sex workers, fisher folk, and plantation workers at TASO, Entebbe, and truckers at TASO, Jinja. Focusing outreach on key populations allowed providers to identify more people who were HIV positive compared to nonfocused testing of general population. At the TASO, Mbarara, site, the positivity rate was 14.5% in sex workers and 6.3% when testing truckers. By comparison, the overall HIV prevalence in Mbarara district was 6.1%.
Integrated out-of-facility testing such as door-to-door testing is combined with other community health outreach and targets people who cannot easily access facilities for services. In Maseno, Kenya, HIV home-based counseling and testing (HBCT) helped increase HIV case detection. In 2 regions of Kenya, Nyanza and Nairobi, there was an average of 9%–10% increase in new HIV cases detected after the launch of HBCT campaigns.
Integrated in-facility testing joins testing between programs, such as HIV and TB, at multiple service points within the facility. This is referred to as integrated facility-based provider-initiated screening and testing, which was found in facilities with high volume of clients. Nonintegrated testing involves clients moving from one room to the other, such as from the antenatal care clinic to a laboratory, rather than offering services at a single point of care. In Mukono Health Centre (TC) in Uganda, integrated services for HIV, TB, antenatal care, and maternity care were provided. With integrated HIV testing at all of the stations, Mukono Health Centre was able to test an additional 100 clients each day and start treatment for those that tested positive as a “one stop shop” service.
Differentiated Treatment and Care
Differentiating clinic attendance allows for sites to designate special clinic days to specific groups of clients. In 2011, the health center in Riruta, Kenya, began to dedicate the last Thursday of the month for children allowing them to benefit from a child-friendly dedicated space and targeted health talks. Since then, the retention of children on ART has improved, with a 28% decrease in LTFU.
Although some sites allocated special times for different clients, some went further to enhance the clinical space. Differentiated clinics dedicate specific waiting areas or clinic space to specific client groups such as a children's clinic, antenatal clinic, or a TB/HIV clinic, and these may occur simultaneously on the same day. At Kericho district hospital in Kenya, TB and HIV treatment were provided at the same service delivery point. This reduced waiting times for clients and improved TB success rates as well as reduction in LTFU. In 2010, coinfected clients had a TB treatment success rate of 75%, compared with 40% in 2005, the year before services were integrated. LTFU reduced from 35% in 2005 to 13% in 2010.
Differentiated client flow allows for sites to designate specific service pathways for specific groups of clients. The sites set criteria and clinic flow for each client group identified as needing a specific pathway. This was observed in 5 sites in Uganda. At TASO Jinja health center in Uganda, clients were triaged when they entered to determine what services they need: pre-test or post-test counseling, HIV testing, visit to nurse or doctor, and laboratory testing such as CD4 count. By shortening pathways and cutting out unnecessary waits, this reduced client waiting time and maximized the utility of staff time (Fig. 1). In Jinja, 15% of clients had finished in the 1st hour compared with 0% with the median clinic time being 3 hours compared with 4 hours in Mulago.
Differentiated Drug Delivery
Provision of differentiated appointment times is an approach that tailors the space between appointment visits to clients' needs. For instance, established and stable HIV clients received the maximum follow-up of 3 months for drug refills or clinical consultations. In Riruta Health Center in Kenya, after tailoring to clients' needs in response to long wait times, the LTFU on 3- and 4-month drug refills was 10% and 4%, respectively, compared with overall LTFU of 26% for the facility.
Facility-based drug delivery was conducted through either fast-track drug refill or drug distribution points. Fast-track drug refill allows for the client to bypass steps in the care pathway. In this case, a stable client with good adherence can go directly to the pharmacy for refills rather than spending additional time in the clinic. At Homa Bay County in Kenya, they offer 6-month clinical appointments and fast-track drug refills every 3 months for stable clients. Of the 1839 clients enrolled, 86% of clients on 6-month refills and 83% on 3-month refills attended their appointments.
Facility-drug distribution points allow for the distribution of drugs to stable clients attending adherence clubs at the facility. These are facilitated by expert clients or peer educators with referrals to doctors, when required. At TASO sites in Uganda, there were facility-drug distribution points for stable clients. Peripheral health facilities such as health posts or dispensaries serve small groups of 10–15 clients, reducing burden on the health facility. At Kombewa hospital in Kenya, clients were referred to lower level facilities, equipped and trained by their staff.
In some communities, drug delivery occurred at community drug distribution points (CDDPs) or community client-led ART delivery (CCLAD) sites. Clients can visit every 2–3 months to pick up medication or have blood samples taken. In TASO Uganda, 60% of their clients on ART received community care, and these clients saw better CD4 evolution (6% increase), fewer appointments missed (13% less), and higher 12-month retention than clients receiving ART at the facility level (10% increase).
With community-based drug delivery by client groups, members of a stable ART group take turns collecting drugs from the clinic or CDDP and deliver them to individuals. In addition, they provide adherence support and monitoring for drug side effects. At TASO sites in Uganda, CCLADs have achieved similar treatment outcomes compared with facility-based models and community-based drug delivery by facility staff. CCLADs and CDDPs have an 88% adherence rate compared with facilities at 89%.
In facilities with differentiated approaches, other distinct management practices were noted. These “enablers” complemented and enforced the differentiated approaches. Three groups of enablers were observed (see Annex 4, Supplemental Digital Content, http://links.lww.com/QAI/B317).
Knowledge Sharing Networks
From field observations and discussions, knowledge-sharing networks, or communities of practice, allowed for sharing of best practices and learnings across different facilities. For example, in Kisumu, Kenya, indicators for linkage to HIV care, prevention of mother-to-child transmission, treatment, pediatrics, and adults are tracked for its 22 facilities with quarterly meetings to discuss and share practices. Mapping performance across facilities identifies opportunities to adapt best practices from one high-performing facility to another with poorer performance.
Effective Data Management
In Kenya, 5 sites measured client-centric indicators, reviewing performance for quality improvement. In Kitebi Health Center in Uganda, clients were categorized into population groups and documented in custom registers, which are used to plan and monitor targeted interventions.
Human Resource Management
Nonmonetary compensation offered in-kind compensation and revenue-generating activities to employees. In Coptic, Kenya, regular staff meetings, feedback from managers, and incentives such as provision of study leave helped reduce staff turnover by 86%.
Career development offered trainings and career development on site. In Coptic HC, Kenya, there are opportunities for trainings and study leaves for additional learning to increase staff retention. In Uganda, TASO sites open management positions to staff with no medical background.
“At TASO, only 2 out of 11 centre managers are doctors so every counselor or lab technician knows they can grow here if they want”—TASO Management
Improving work environments by enhancing on-site infrastructures, medical facilities, and working interactions also seek to improve work conditions. Previously in Kitebi, Uganda, staff left work early because of lack of access to clean toilets. As a solution, separate toilets for staff were introduced. At Wakiso Health Centre in Uganda, tea and bites were offered to 36 health workers early in the morning, leading to a 25% increase in day-to-day effective working time. A cordial working environment improved staff retention at TASO, Masaka.
“People are staying at TASO because of the family spirit. I know I will not find a similar culture elsewhere”—Staff at TASO-Masaka
Recognition through performance-based incentives and rewards was also used. At Kiswa and Wakiso HCs in Uganda, and Coptic in Kenya, staff of the month and staff of the year awards were distributed, and pictures of winners were displayed on the wall. This helped to motivate and boost morale of the staff.
“Employees like their photos to be displayed as people recognise them as the award recipient… they ask for a copy of the announcement to show their families and proudly attach it to their CVs”—HR Manager (Coptic)
This study identified several different approaches used by facilities to overcome bottlenecks of implementation in service provision. These included tailoring approaches more closely to the needs of specific clients, for which the term differentiation is used, and a set of facility enablers or management approaches to improve the work experience. Differentiated approaches and enablers adapted across the HIV care continuum have the potential to improve service accessibility and efficiency.18 This can enhance the quality of the client experience and ensure the health system functions in an accountable and efficient way.19 Having reliable systems for collecting routine data and the effective use of these data allow for facilities to better understand their processes, gather insights on their client demographics, identify risk groups, and improve access to quality care.20
Many health facilities also face human resource challenges such as low staff motivation and retention, substantial absenteeism, and a large number of vacancies. As such, having strong human resource management systems becomes essential to increasing motivation and retention of staff and for developing an integrated people-centered approach to health services.21
Since this work began in 2015, several countries have advanced the differentiated care focus by revising national policies and guidance, applying these models to different population settings, and measuring the cost savings potential for some of these service delivery models.22 Guidance on differentiated care has evolved for advanced HIV clients, adolescents, children, pregnant and breastfeeding women, as well as key populations.19 Differentiated service delivery for key populations could increase the number of people who know their status if community-based and lay provider testing are implemented at scale,23,24 as seen with community outreach models in Uganda.
With almost all countries adopting WHO recommendations to provide immediate and lifelong ART to people living with HIV regardless of their CD4 count,25 replicating differentiated approaches may help reduce the demand pressure on health facilities and increase focus on individuals with the greatest need, as seen in Uganda TASO sites. Tailoring approaches to the facility's daily client intake and available resources can help deliver the appropriate care at the ideal service frequency to specific individuals.26
Implementing differentiated care models has certain caveats. First, health workers and facilities need to be motivated with incentives, financial or nonfinancial, as seen in health facilities in Uganda. Second, health facilities may face challenges in implementing differentiated care, which takes time and effort with the current focus on rapid scale-up of numbers on treatment, potentially sacrificing quality for rapid expansion. Host governments and donors should seek to create enabling environments for processes which may improve the quality of service delivery and reward facilities that achieve these improvements. Third, many health facilities in resource-limited settings lack the processes and systems needed for improving knowledge and documenting changes over time, but this can be addressed by implementing knowledge sharing networks and systems for sharing of best practices.27 Finally, programmatic changes, such as providing training or career development, and building systems to improve staff conditions may require frontloading financial investments to improve program quality and efficiency.
Natural observation studies suffer from limitations related to sampling and reporting bias. Thus, the inferences from this study may be limited by the purposefully selected sample and selective reporting from interviews.13 A standard questionnaire and interview guide were used for observations for all facilities. Although, this does not eliminate all bias, the findings are still useful for governments and implementers in understanding innovations in HIV service delivery. Understanding the practices that occur in real-life settings allows for these to be adapted in other settings, under trial conditions, providing opportunities for future research.
At the facility level, many services address systems and financial constraints in innovative ways. Scaling up differentiated care models may offer a pathway to address programmatic constraints in low-resource settings. However, more studies are needed including costing studies to better understand potential efficiency gains.28 In addition, key metrics for measuring program improvement using financial data and the number of refill and clinical visits for clients retained in care will be practical for program managers to use.29
Differentiated models of care for HIV should be viewed as part of the wider focus on health systems strengthening. Tailoring services to population need can be applied to other types of service delivery across both communicable and noncommunicable diseases, critical to both global and national policy agendas. Replicating these models to scale will require on-going monitoring, so site managers can take strategic actions using client-centric indicators, integrating communities into workforce planning, and sharing of best practices across facilities to improve the quality of service delivery.
The authors would like to acknowledge the support of the Kenya MOH and Uganda MOH. They would also like to thank Saman Zamani, the GF Uganda Country Team, John Ochero, Caroline Olwande, Dr. Martin Sirengo, Swetha Balachandran, Johanna Benesty for their support and contributions.
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HIV; differentiated care; service delivery; quality of care; efficiency
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