Decision Framework

Differentiated ART delivery for children, adolescents and pregnant and breastfeeding women

A Decision Framework for differentiated antiretroviral therapy delivery for children, adolescents and pregnant and breastfeeding women draws purposeful attention to these specific populations. It is the second of the Decision Framework series and supports how to implement the 2017 Key considerations for differentiated antiretroviral therapy delivery for specific populations: children, adolescents, pregnant and breastfeeding women and key populations (see WHO section below for more detail).

Global Guidance

WHO

The World Health Organization (WHO) provides guidelines, recommendations and key considerations to support differentiated care across the HIV care continuum. The 2016 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection recommend a differentiated care approach to address the diverse needs of people living with HIV.

Since the 2016 WHO consolidated ARV guidelines were developed, appreciation has been growing that different types of clients may also benefit from models of care specifically for clinically stable clients. The 2017 Key considerations for differentiated antiretroviral therapy delivery for specific populations: children, adolescents, pregnant and breastfeeding women and key populations outlines the rationale for and features of differentiated ART delivery for clinically stable clients in these populations. The document complements A Decision Framework for differentiated antiretroviral therapy delivery for children, adolescents and pregnant and breastfeeding women (see above, Decision Frameworks).

The 2017 Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy also include differentiated care, or differentiated service delivery. This guideline adds recommendations for appropriate packages of care for clients presenting or returning to care with either advanced HIV disease or when clinically well.

In July 2017, WHO prequalified the first HIV self-test. WHO has recommended HIV self-testing since November 2016 when they released a supplement guideline on HIV self-testing and partner notification. This supplement was to the 2015 Consolidated guidelines on HIV testing services.  

WHO also has Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations and Consolidated guidelines on person-centred HIV patient monitoring and case surveillance

GFATM

The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) released a toolkit in November 2015 to provide operational guidance to managers of health facilities on implementing differentiated care approaches. GFATM also released their HIV Information Note in December 2016 to provide guidance to applicants developing Global Fund funding requests for the 2017-2019 funding cycle. Differentiated care is described as a key strategy to achieve this and reach the UNAIDS fast track prevention and treatment targets. 

UNAIDS

The 2017 Global AIDS Update from UNAIDS, Ending AIDS: Progress Towards the 90-90-90 targets, recognizes that an increasing number of countries are using differentiated care models to establish community-based systems for providing services across the cascade and making the 90-90-90 targets a reality. In 2015, UNAIDS partnered with Medécins Sans Frontières (MSF) to release the first in a series of case studies highlighting the need to adapt ART delivery systems to meaningfully include community-based services. 

PEPFAR

COP/ROP 2017 identifies differentiated models of ART delivery as a priority strategy requiring the United States President’s Emergency Plan for AIDS Relief (PEPFAR) support for country policy development and implementation. Attention is drawn to the need to include children, adolescents and pregnant and breastfeeding women and key populations (pg 157-158). Focus is also placed on the importance of human resources for health planning, specifically the use of community-based or lay cadres to facilitate such differentiated ART delivery models and decrease facility visits to once a year for stable clients (pg 170).

USAID's Supply Chain for Health team has put together an antiretroviral (ARV) planning tool to help countries consider their ARV procurement and supply chain planning for implementing i. “treat all” and ii. longer ART refills, also known as multi-month scripting (MMS).

MSF

Medécins Sans Frontières (MSF) released its first report, Closer to Home, in 2012 (updated version in 2013) on community-based models of ART delivery that it had been piloting for stable clients in sub-Saharan African countries in partnership with country health authorities. Lessons from implementation in Malawi are summarized in the 2015 report Lessons learnt from implementing CAGs in Thyolo, Malawi

Guidance on how to implement models of differentiated ART delivery are also available from MSF in the Resource Library, including a toolkit for client-managed groups known as Community ART Groups in English and French, a report and toolkit for health care worker managed groups known as Adherence Clubs as well as for Family Clubs and for an out-of-facility model, or PODI, available in English and French. 

Up the care cascade, a report and toolkit on ART/TB/PMTCT initiation patient education and counselling from the MSF Khayelitsha project is available for download below. 

National Policies

Kenya

Since 2016, the Kenyan Ministry of Health, through the National AIDS & STI Control Programme (NASCOP), has included provision for differentiated care in its updated Guidelines on use of antiretroviral drugs for treating and preventing HIV infection in Kenya, and its practical handbook for HIV managers and service providers on differentiated care Improving the quality and efficiency of health services in Kenya. To accompany the guidelines and practical handbook, NASCOP released a Differentiated Care Operational Guide in January 2017. 

Mozambique

To guide key stakeholders in the nationwide implementation of Community Adherence and Support Groups (CASG), the Mozambican Ministry of Health released a Community Adherence and Support Groups Strategy in 2015. The document describes in detail the model, eligibility criteria, patient flow and monitoring and evaluation procedures. CASGs are an example of client-managed groups. For more details on client-managed groups, click here.

South Africa

The South African National Department of Health launched the National Strategic Plan (NSP) for HIV, TB and STIs 2017-2022 on March 31st 2017 which states that all people living with one or more of the three diseases covered by the NSP will have access to differentiated service delivery. A document summarizing the goals and objectives of the new NSP highlights differentiated care as a ‘game-changer’.

In February 2016, the National Department of Health released its Adherence Guidelines for HIV, TB and NCDs which require phased implementation at each ART facility of one or more differentiated ART delivery model.

The Southern African HIV Clinicians Society published guidelines in 2017 recommending strategies to support adolescents and young adults in achieving and maintaining viral suppression. These are the first in sub-Saharan Africa to recognize the need to differentiate service delivery models appropriate for stable or unstable adolescents and young adults in either their first year of treatment or thereafter. In 2017, the Southern African HIV Clinicians Society released a supplement guideline on HIV self-testing.

Swaziland

The Swaziland National AIDS Programme’s National Policy Guidelines for Community-centred Models of ART Service Delivery (June 2016) recognize the need for differentiation throughout the treatment pathway and specifically provide guidance for stable client management. They are accompanied by a set of Standard Operating Procedures.

Tanzania

In a joint effort, the Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) and International Training and Education Centre for Health (I-TECH) released HIV Service Delivery Models: Mapping HIV Service Delivery Strategies in Tanzania in 2017.

Zambia

The Zambian Ministry of Health (MoH) released Consolidated Guidelines for Treatment and Prevention of HIV Infection in 2016 outlining a differentiated care framework characterized by four delivery components.

Zimbabwe

The Zimbabwe Ministry of Health and Child Care (MoHCC) released an updated Operational and Service Delivery Manual for the Prevention, Care and Treatment of HIV in Zimbabwe (OSDM) in February 2017. It sets out ‘how’ to implement WHO’s 2016 clinical guidelines, including differentiated service delivery across the entire HIV cascade from testing through to suppression. The manual also includes standard operating procedures (SOPs) and outlines the five step process for deciding how to differentiate service delivery at a district level. To accompany the manual, the Zimbabwe MoHCC also developed the Consolidated HIV and AIDS Job Aide that includes checklists, clinical algorithms and educational tools to support implementation.