In May 2016, the Kenyan Ministry of Health, through the National AIDS & STI Control Programme (NASCOP), released: 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, entitled “Improving the quality and efficiency of health services in Kenya”.
The guidelines specifically recognize and outline a differentiated care approach for the ART initiation period and ART delivery thereafter. It stipulates the building blocks of a model of care from ART initiation throughout the first year on ART for well clients versus clients with advanced HIV disease (pg 24-27). It similarly outlines the building blocks of a model of care for stable versus unstable patients after their first year on ART (pg 28-32). Each differentiation category is clearly defined with the package of care, location of services, service provider, frequency of services and a summary of clinical and laboratory monitoring outlined for each group. It further provides flexibility in choice of ART delivery model for stable patients, allowing for facility and community distribution variations, and includes examples. It sets out the criteria that must be met before implementing community-based distribution, which includes already having a facility-based fast-track system in place (pg 32).
The practical handbook recognizes the need for differentiated care, and takes the approach of describing a collection of differentiated care models throughout the HIV cascade, mostly from Kenya and also drawing from best practice examples in other sub-Saharan African contexts. It focuses on differentiated model implementation using a quality improvement framework approach. It provides examples of differentiation approaches for ART delivery for stable patients including: decentralized drug delivery at peripheral clinics and fast-track drug refills (facility-based individual models); facility-based distribution groups (health care worker-managed group model); decentralized drug delivery by health staff in communities (out-of-facility individual model); and community-based drug delivery where drugs are delivered by patient groups (client-managed group model). It also provides examples of longer drug refills (up to four months) resulting in increased appointment spacing.
To accompany the guidelines and practical handbook, the Kenyan Ministry of Health, through NASCOP, released a Differentiated Care Operational Guide in January 2017. The guide is a healthcare worker handbook designed to equip service delivery providers with strategies for implementing differentiated care as described in the Guidelines on Use of Antiretroviral Drugs for Treating and Preventing HIV Infection in Kenya (2016 Edition). It provides step by step guidance and details country and facility level planning approaches, implementation strategies and how to monitor and evaluate differentiated care. Focus is placed on categorizing patients based on clinical characteristics and the guide includes tools and job aids for implementing differentiated care.