Differentiated service delivery models for HIV treatment in Malawi, South Africa, and Zambia: A landscape analysis

Introduction: Many countries in Africa are scaling up differentiated service delivery (DSD) models for HIV treatment, but most existing data systems do not describe the models in use. We surveyed organizations that were supporting DSD models in 2019 in Malawi, South Africa, and Zambia to describe the diversity of DSD models being implemented at that time. Methods: We interviewed DSD model implementing organizations for descriptive information about each model of care supported by the organization. We described the key characteristics of each model, including population of patients served, location of service delivery, frequency of interactions with patients, duration of dispensing, and cadre(s) of provider involved. To facilitate analysis, we refer to one organization supporting one model of care as an organization-model. Results: The 34 respondents (8 in Malawi, 16 in South Africa, 10 in Zambia) interviewed described a total of 110 organization-models, which included 19 facility based individual models, 21 out-of-facility based individual models, 14 healthcare worker led groups, and 3 client led groups; jointly, these encompassed 12 service delivery strategies. Over 2/3 (n=78) of the organization-models were limited to clinically stable patients. Almost all organization-models (n=96) continued to provide clinical care at established healthcare facilities; medication pickup took place at facilities, external pickup points, and adherence clubs. Required numbers of provider interactions per year varied widely, from a low of 2 to a high of 12. Dispensing intervals were typically 3 or 6 months in Malawi and Zambia and 2 months in South Africa. Individual models relied more on clinical staff (doctors, nurses, pharmacists), while group models made greater use of lay personnel (community health workers, counselors). Conclusions: As of 2019, there was a large variety of differentiated service models being offered for HIV treatment in Malawi, South Africa, and Zambia, serving diverse patient populations.