Date Published: November 21, 2017
Publisher: Public Library of Science
Author(s): Ruanne V. Barnabas, Connie Celum
Abstract: In a Perspective, Ruanne Barnabas and Connie Celum discuss the implications of the accompanying Link4Health and Engage4Health studies for HIV care in sub-Saharan Africa
Partial Text: Both evaluations of the CIS interventions presented by McNairy and Elul and their respective colleagues are client-centered approaches that simplify and adapt services to meet people’s preferences and expectations while reducing unnecessary burdens on the health system—known as differentiated service delivery (DSD) [5,6]. DSD could facilitate achieving the 90-90-90 goals by reaching persons not currently in the health system and by maximizing health outcomes within constrained resources. Both the Engage4Health and Link4Health studies worked within public clinics demonstrating that CIS implementation and evaluation are feasible and acceptable, albeit with the additional resources provided through a research study. Nevertheless, these studies provide clear guidance on how clinics could streamline services and meet client needs. Specifically, reducing the number of steps to ART initiation remains relevant in the current era of offering ART to all people testing positive for HIV, irrespective of CD4 cell count. An example is the approach of Médecins Sans Frontières, in which adherence counseling is tailored to barriers identified for individual people, rather than providing comprehensive adherence counseling to all, with the benefit of reducing provider and patient time and streamlining the steps to ART initiation [7,8]. South Africa has recently provided guidance for ART initiation on the same day of HIV diagnosis for clinically stable patients, with people returning seven days later for review of baseline laboratory measurements and symptoms, further reducing delays to ART initiation .
DSD is an important focus area due to the challenges of strained health facilities being able to accommodate a rapidly growing number of HIV-positive persons entering HIV care. Many DSD strategies attempt to address the barriers of long waits and monthly medication refills and need to be robustly evaluated to measure their impact on health, costs, and scalability . Indeed, not all DSD interventions are effective, such as the financial incentives in the Engage4Health Study, which was not shown to improve linkage and retention, although that comparison might have been underpowered. Notably, the Link4Health and the Engage4Health studies are implementation sciences studies which were conducted in public HIV programs in Swaziland and Mozambique, respectively, and encountered challenges of assessing outcomes with missing health records, incomplete electronic records, and limitations of missing data in terms of whether participants linked to care elsewhere, were no longer in care, or died. However, these limitations of implementation science research are balanced by increased generalizability and relevance to scalable delivery models. Future DSD studies would benefit from improved data capture and tracking, which are necessary to ascertain outcomes at both the individual and population levels.
The Link4Health and Engage4Health studies represent the beginning of making HIV care streamlined and more client-centered. Changes in HIV treatment, which are likely to include longer-acting ART formulations [11,12] and integration of other chronic disease diagnosis and management into HIV care platforms [13,14], present opportunities for continued re-engineering of health systems. Building on the two studies presented in this issue and anticipating future changes, key priorities for future work include: first, reaching people who know their status but are not engaged in HIV care as they are missing from the HIV care continuum; and second, consistently and reliably reporting the impact on health, particularly viral suppression, and over longer durations than 12 months of follow-up. Routine evaluation of health outcomes requires robust clinical records and reporting that accounts for missing data, and in many cases, this will require strengthening data capture systems. Surveillance can play a key role in providing evidence for key gaps in routine data . Lastly, operations research into new strategies also requires rigorous assessment and further work is needed on adaptive interventions , which will be essential as additional delivery options are developed for treatment of HIV-positive persons. Collectively, implementation and evaluation of innovative differentiated care models should bring us closer to the UNAIDS 90-90-90 goals.