In this edition, we focus on recent policy changes impacting access to pre-exposure prophylaxis (PrEP) in Thailand and DSD demand creation efforts in Mozambique.
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Welcome to the first differentiated service delivery (DSD) newsletter of 2023 from IAS – the International AIDS Society. In this edition, we focus on recent policy changes impacting access to pre-exposure prophylaxis (PrEP) in Thailand and DSD demand creation efforts in Mozambique.

PrEP policy change in Thailand: Taking a huge step backwards 

Rena Janamnuaysook, Institute of HIV Research and Innovation, Thailand, writes: 


Key population-led organizations have historically been a major contributor to the success of PrEP rollout in Thailand. Over 80% of current PrEP users in Thailand receive PrEP at key population-led clinics across the country. This is a testament to the strengths of key population-led organizations in enhancing equity in HIV prevention service delivery to key populations. 


However, in December 2022, the Ministry of Public Health denounced key population-led organizations to dispense same-day PrEP at their clinics. Regaining their ability to provide PrEP requires entering into a contract with a government hospital and surrendering their PrEP-dispensing authority to the public health facility. Thousands of current and future PrEP clients of these key population-led clinics will now have to refill or start PrEP at government hospitals, no matter the distance or cost.


This announcement will have a massive detrimental impact on Thailand’s national PrEP programme. It will reintroduce logistical barriers to accessing HIV prevention for key populations, leading to further delays in achieving the 2030 goal of ending AIDS as a public health threat, nationally and globally.


PrEP and other HIV prevention services should and must be accessible anywhere – from government or private hospitals and key population-led clinics – regardless of their registered healthcare schemes. Facility and eligibility discordance prevented life-saving access in the past, and we should strive to never repeat it.  


Read the full piece

 

DSD in action: Demand creation in Mozambique

"We want clients to have information about DSD models that exist at their health facilities to enable them to demand enrolment in DSD models. That’s why it is important that clients have the correct knowledge of DSD eligibility criteria."

We spoke with Lourenço Sumbane, Communications Adviser at the Civil Society Platform for Health in Mozambique (PLASOC-M).


What is PLASOC-M’s mission and how does it relate to DSD?


We advocate for improvement of the quality of health for Mozambicans, as well as reduction of HIV acquisitions and HIV-related deaths. To fulfil this mission, we have developed coordination and training activities for member organizations. The objective of this training is to influence the Ministry of Health to make provisions for the meaningful engagement of people living with HIV in the planning, design, implementation and monitoring of HIV policies.


Activity reports of PLASOC-M and the ministry show that there are high rates of treatment interruption. We identified one of the reasons as the fact that clients do not have information about DSD and DSD eligibility criteria. As a result, PLASOC-M developed advocacy actions and supported civil society organizations in creating demand for DSD at the health facility level.


What are the key messages of your demand creation and treatment literacy activities?


We want clients to know about the U=U (undetectable equals untransmittable) campaign and that the aim is for all clients on ART to be virally suppressed. For that to happen, clients must be supported to adhere to their treatment. We also want clients to have information about DSD models that exist at their health facilities to enable them to demand enrolment in DSD models. That’s why it is important that clients have the correct knowledge of DSD eligibility criteria. At the policy level, we are advocating for the Ministry of Health to involve clients in design, implementation and monitoring because ultimately these services are for them.

Read the full interview

 

Don't miss

DSD science at CROI 2023


Check out this exciting data from South Africa where people in community-based ART delivery models who had annual clinical visits had non-inferior retention and viral suppression compared with people who had six-monthly clinical visits.

 

Looking ahead, looking back

Looking ahead …

  • Register for IAS 2023, the 12th IAS Conference on HIV Science, which takes place from 23 to 26 July in Brisbane, Australia. Satellite bookings close on 30 March and standard registration closes on 3 May.
  • Sign up for AVAC’s post-Conference on Retroviruses and Opportunistic Infections (CROI) webinar, “Been There, Did That - Research Reflections from CROI 2023”, to be held on 23 March.
  • Register here for the IAS webinar, “Making PrEP accessible: Updates on long-acting injectable options”, to be held on 30 March 2023.
  • Check out the programme of the INTEREST conference, which takes place on 9-12 May in Maputo, Mozambique.
     

Looking back …

  • Read the new PLOS Medicine article, "The future of HIV testing in eastern and southern Africa: Broader scope, targeted services", which describes the importance of HIV testing services (HTS) for prevention, treatment and re-engagement in eastern and southern Africa. This paper was developed based on outputs from a 2021 expert consultation convened by the IAS, the World Health Organization (WHO) and the Bill & Melinda Gates Foundation (BMGF).
  • CQUIN hosted an all-network differentiated testing and linkage meeting to discuss key issues related to the differentiated HIV testing cascade on 13-16 March in Nairobi, Kenya.
  • In February 2023, PEPFAR launched the final 2023 COP/ROP Guidance and FY24 Technical Considerations. Related co-planning meetings with country stakeholders were held in Johannesburg, South Africa, in February and March. 
  • The 30th CROI was held in Seattle, the United States, from 19 to 22 February 2023. Watch the opening session and explore the programme.
  • Ritshidze, a community-led monitoring system developed by organizations representing people living with HIV, published the 2nd edition of the State of Healthcare for Key Populations report, including survey data collected from over 9,000 people accessing services in South Africa.
  • View the recordings of the webinar, “Centering Recipients of Care: Assessing and Improving Satisfaction within DSD Programs”, and the webinar, “DSD for Adolescents and Young People”, both organized by CQUIN of ICAP at Columbia University.   

 

What we're reading

Similar costs and outcomes for differentiated service delivery models for HIV treatment in Uganda, Guthrie T et al, BMC Health Services Research, November 2022 


This cost-outcome study estimated the total annual costs associated with clients on treatment and the total annual cost per client virally suppressed in Uganda’s five DSD models. Service delivery costs (excluding ARVs) were modest, ranging from USD 9.66 to USD 16.43 per client per year. The authors conclude that DSD for HIV treatment in Uganda achieved excellent treatment outcomes at a cost similar to the standard of care.

How soon should patients be eligible for differentiated service delivery models for antiretroviral treatment? Evidence from a retrospective cohort study in Zambia, Jamieson L et al, BMJ Open, December 2022 


To assess whether a “time on ART” eligibility criterion is necessary, this retrospective cohort study compared loss to follow up (LTFU) between clients enrolling in DSD models early (after <6 months on ART) with those enrolled according to the national guidelines (≥6 months on ART). LTFU at 18 months was 3% for early enrollers and 5% for established enrollers. Early enrollers were 41% less likely to be lost to follow up than established clients.

Experiences and Perceptions on Community Client-Led ART Delivery (CCLADS) Model of Antiretroviral (ART) Delivery: Patients’ and Providers Perspectives in South Western Uganda, Kasande M et al, HIV/AIDS-Research and Palliative Care, November 2022 


This descriptive qualitative study explored the experiences and perceptions on the community client-led ART delivery groups (CCLADs) model from client and provider perspectives. The authors conclude that participation in CCLADs provides benefits to clients, including reduced transport, longer refills and good adherence. Stigma remains a challenge to participation in CCLADs and must be addressed to sustain this participation.

Effectiveness of a peer educator-coordinated preference-based differentiated service delivery model on viral suppression among young people living with HIV in Lesotho: The PEBRA cluster-randomized trial, Kopo M et al, PLoS Med, January 2023 


This cluster-randomized trial compared the peer educator-based refill of ART (PEBRA) model with standard clinic care (no peer educator and ART refill done by nurses) in three districts in Lesotho. At 12 months, 66% of participants in the intervention versus 61% in the control arm had viral suppression. Preference-based peer-coordinated care for young people living with HIV, compared with nurse-based care only, did not significantly impact viral suppression.

Expanding Access to Oral Preexposure Prophylaxis for People Who Inject Drugs in Bayelsa and Niger States, Nigeria, Nishimoto L et al, Global Health: Science and Practice, February 2023 


This case study described the implementation of a community-based programme to increase access to and uptake of oral PrEP services among people who inject drugs. The programme provided a comprehensive package of services, including HIV testing, sexually transmitted infection screening, oral PrEP, risk reduction counselling, and other health and support services. While the provision of oral PrEP services to people who inject drugs in Nigeria was shown to be feasible, the authors emphasize the need for greater efforts to improve service access among hard-to-reach sub-populations.  

A Sequential Multiple Assignment Randomized Trial of scalable interventions for ART delivery in South Africa: the SMART ART study, van Heerden A et al, Trials, January 2023 


This study protocol for a sequential multiple assignment randomized trial to be undertaken in KwaZulu-Natal, South Africa, will test adaptive ART delivery for people with detectable viral load and/or who are not engaged in care. The types of DSD models that will be examined in this study are clinic-based incentives, community-based smart lockers and home delivery.

 

What we're watching

Implementing long-acting injectable PrEP with an eye toward equity: Yale’s LaRon Nelson at CROI 2023


Watch this HIV.gov interview with LaRon Nelson of Yale University held during CROI 2023 about his presentation, “Inevitable Inequalities: Why We Keep Making the Same Mistakes and How We Can Stop It”, delivered at the symposium, “Delivering on the Success of Injectable PrEP”.

 

Get in touch

Do you have content for the next newsletter? We want to hear from you.
Email us at dsd@iasociety.org.


www.differentiatedservicedelivery.org

 

Photo credits in order of appearance: 
(1) IHRI, (2) Mariana Abdalla/MSF, (3) HIV.gov

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