Enhancing HIV treatment and support: a qualitative inquiry into client and healthcare provider perspectives on differential service delivery models in Uganda

Background: HIV/AIDS continues to be a significant contributor to illness and death, particularly in sub-Saharan Africa. In this study, we conducted a qualitative assessment to understand Client and Healthcare Provider Perspectives on Differential Service Delivery Models in Uganda. The purpose was to establish strengths and weaknesses within the services delivery models, inform policy and decision-making, and to facilitate context specific solutions. Methods: Between February and April 2023, a qualitative cross-sectional study was utilised to gather insights from a targeted selection of individuals, including People Living with HIV (PLHIV), healthcare workers, HIV focal persons, community retail pharmacists, and various stakeholders. The data collection process included eleven in-depth interviews, nine key informant interviews, and eight focus group discussions carried out across eight districts in Central Uganda. The collected data was analyzed through inductive thematic analysis with the aid of Excel. Results: The various Differentiated Service Delivery Models (DSDMs), notably Community-Client-Led Drug Distribution (CCLAD), Community Drug Distribution Point (CDDP), Community Retail Pharmacy Drug Distribution Point (CRPDDP), and the facility-based Facility Based Individual Model (FBIM), were reported to have several positive impacts. These included improved treatment adherence, efficient management of antiretroviral (ARV) supplies, reduced exposure to infectious diseases, enhanced healthcare worker hospitality, minimized travel time for ART refills, stigma reduction, and decreased waiting times. Concern was raised about the lack of improvement in HIV status disclosure, opportunistic infection treatment, adherence to seasonal appointments, and sustainability due to the overreliance of the DSDMs on donor funding, suggesting potential discontinuation without funding. Doubts about health workers’ commitment surfaced. Notably, the CCLAD model displayed self-sustainability, with clients financially supporting group members to collect medicines. Conclusion: Community-based DSDMs, such as CCLAD and CDDP, improve ART refill convenience, social support, and client experiences. These models reduce travel and waiting times, lowering infection risks. Addressing challenges and enhancing facility-based models is vital. In order to maintain funding after donor funding ends, sustainability measures like cross-subsidization can be used. If well implemented, the DSDMs have the potential to produce better or comparable ART outcomes compared to the FBIM model

Scaling up paediatric HIV care with an integrated, family-centred approach: an observational case study from Uganda.

Family-centred HIV care models have emerged as an approach to better target children and their caregivers for HIV testing and care, and further provide integrated health services for the family unit's range of care needs. While there is significant international interest in family-centred approaches, there is a dearth of research on operational experiences in implementation and scale-up. Our retrospective case study examined best practices and enabling factors during scale-up of family-centred care in ten health facilities and ten community clinics supported by a non-governmental organization, Mildmay, in Central Uganda. Methods included key informant interviews with programme management and families, and a desk review of hospital management information systems (HMIS) uptake data. In the 84 months following the scale-up of the family-centred approach in HIV care, Mildmay experienced a 50-fold increase of family units registered in HIV care, a 40-fold increase of children enrolled in HIV care, and nearly universal coverage of paediatric cotrimoxazole prophylaxis. The Mildmay experience emphasizes the importance of streamlining care to maximize paediatric capture. This includes integrated service provision, incentivizing care-seeking as a family, creating child-friendly service environments, and minimizing missed paediatric testing opportunities by institutionalizing early infant diagnosis and provider-initiated testing and counselling. Task-shifting towards nurse-led clinics with community outreach support enabled rapid scale-up, as did an active management structure that allowed for real-time review and corrective action. The Mildmay experience suggests that family-centred approaches are operationally feasible, produce strong coverage outcomes, and can be well-managed during rapid scale-up

Client flow pathway into HIV care and treatment within family-centred approach.

<p>Figure demonstrates the patient flow at integrated facilities; the pathway has been adapted from the WHO Integrated Management of Adult Illness sequence of care. Entry points into family-based points including outpatient care, maternal and child health clinics, antenatal care, inpatient admissions, and community-based outreach. Clients then proceed through triage assessments, education and support as required, assessment of client and family health status, care and treatment as required, positive prevention for HIV-infected clients, and follow-up care services.</p

Capacity building for integrating family-centred care at partner facilities.

<p>Figure describes the courses designed by Mildmay and made available during partner facility service integration, as needs assessments determine. These include short-term (week) courses on skills sets like pediatric HIV nursing or laboratory skills, modular courses on more advanced subjects like community-based HIV care and health systems approaches, and training for community volunteers on HIV/AIDS basics and counseling skills.</p

Possibilities for integrated service package for family-centred care.

<p>Figure displays recommended services listed within four sub-headings: HIV and TB care, paediatric and adult primary care, psychosocial and economic support, and administrative services.</p

Service approach at health facilities before and after family-centred approach.

<p>Figure describes several service delivery components (e.g. scheduling, counseling, medication refills, and community engagement) before and after the family-centred approach. The figure demonstrates considerable effort to re-align the service approach to make it family-friendly, for example, same-day scheduling for families or fast-tracking families with children for services.</p

Cumulative trend of uptake of paediatric care after introduction of family-based approach at Mildmay main site in 2003.

<p>Figure demonstrates uptake trends from 1999 to 2010 for three key indicators: number of children and adolescents enrolled in HIV care, number on cotrimoxazole prophylaxis, and number on ART. Uptake data shows sharp increases for all three indicators at 2003, when the family-based approached was introduced at Mildmay.</p

A theme issue by, for, and about Africa [1] (multiple letters)

SCOPUS: le.jinfo:eu-repo/semantics/publishe