Dr Aleny Couto, Director of STI and HIV/AIDS Programmes at the Mozambique Ministry of Health, writes:
In response to COVID-19 in 2020, Mozambique built on the strength of the DSD systems already in place to ensure continued access to treatment for people living with HIV during difficult times of movement restrictions and fear around accessing health facilities.
In March 2020, Mozambique released an emergency circular enabling and scaling up three-month antiretroviral therapy (ART) refills for all, including people newly on treatment, children, pregnant and breastfeeding women, and people with elevated viral loads. Mozambique also implemented new community-based models to support better treatment access: community outreach worker home delivery in rural areas.
In mid-2021, Mozambique decided to take stock ahead of updating the national DSD guidance. We have considered the World Health Organization’s 2021 DSD recommendations, as well as the DSD policy approaches of 32 countries to eligibility criteria (population based, time on ART and ART regimens) and visit frequency through these helpful country policy dashboards. We reviewed the DSD acceleration during 2020 and 2021 to evaluate the emergency measures we put in place and determine which would be appropriate to continue post-COVID-19.
In February 2022, the Directorate of Public Health approved a new policy supporting a maximum duration of six months for ART in 85 health facilities. We hope to complete the process and launch Mozambique’s updated DSD guidance by mid-2022.
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In Kenya, PrEP is dispensed mostly through HIV clinics within public health facilities at quarterly visits. Barriers include stigma from visiting HIV clinics, long wait and travel times, overburdened providers, stock outs and limited hours. DSD for PrEP refills and continuation could empower people to take charge of their own care.
We spoke with IAS Governing Council member Dr Kenneth Ngure, Associate Professor at the School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Kenya, and Dr Katrina Ortblad, Assistant Professor at the Fred Hutchinson Cancer Research Center, United States.
At CROI 2022, you presented the results of a randomized integrated PrEP and HIV self-testing (HIVST) model you implemented in Kenya. Can you describe the service delivery model in detail?
We conducted a randomized non-inferiority implementation trial that tested six-month PrEP dispensing supported with interim HIVST. Participants received either six-month PrEP dispensing with clinic visits at the same frequency supported by HIVST conducted at home after three months or three-month PrEP dispensing with clinic visits at the same frequency and clinic-based HIV testing. The screening and initiation took place at public clinics, whereas PrEP refills and routine clinical follow up took place at the research clinic. The clinical follow-up service package included rapid diagnostic testing, counselling, syndromic STI testing, creatinine testing, screening for symptoms of PrEP side-effects and/or early HIV acquisition.
What are the key findings from this trial?
We found that six-month PrEP dispensing supported by interim at-home HIV self-testing at three months halved the number of PrEP clinic visits while maintaining equivalent HIV testing, PrEP refilling and PrEP adherence at six months compared with standard-of-care PrEP delivery with quarterly clinic visits.
Looking at client outcomes at sub-population level, did you see any significant differences?
Among women not part of HIV serodifferent couples, this model of six-month PrEP dispensing with interim HIVST significantly increased PrEP adherence, measured objectively with blood sampling, compared with standard-of-care PrEP delivery.
What did you learn about clients’ and healthcare workers’ perspectives and satisfaction with the model?
We collected serial qualitative data from clients on their perceived acceptability of this model and experiences at months six and 12. We also collected qualitative data from health providers to capture their perceptions, including how it reduced workload and assisted clients’ PrEP access and use. Responses from clients and providers were mostly positive.
What are the next steps for implementation and scale up?
Our team is excited about the findings from this trial and has plans to evaluate scale up of this model to public facilities in Kenya and the region. Our findings should motivate new DSD models of PrEP refilling supported by HIVST that can help move PrEP continuation outside healthcare facilities. Our team is finalizing the costs and cost savings associated with this new HIVST-supported PrEP delivery model, which will inform future policy decisions.
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