Abstract
The primary goal of antiretroviral treatment is to improve the health of individuals with HIV, and a secondary goal is to prevent further transmission. In 2016, Rwanda adopted the World Health Organization’s “treat-all” approach in combination with the differentiated service delivery (DSD) model. The model’s goal was to shorten the time from HIV diagnosis to treatment initiation, regardless of the CD4 T-cell count. This study sought to identify perceptions, enablers, and challenges associated with DSD model adoption among PLHIV.
This study included selected health centers in Kigali city, Rwanda, between August and September 2022. The patients included were those exposed to the new HIV care model (DSD) model and those exposed to the previous model who transitioned to the current model. Interviews and focus group discussions were also held to obtain views and opinions on the DSD model. The data were collected via questionnaires and audio-recorded focus group discussions and were subsequently analyzed.
The study identified several themes, including participants’ initial emotions about a new HIV diagnosis, disclosure, experiences with transitioning to the DSD model, the effect of peer education, and barriers to and facilitators of the DSD model. Participants appreciated reduced clinic visits under the DSD model but faced transition and peer educator mobility challenges.
The DSD model reduces waiting times, educates patients, and aligns with national goals. Identified barriers call for training and improved peer educator retention. Recommendations include enhancing the DSD model and future research to evaluate its long-term impact and cost-effectiveness.
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References
Siegfried N, Uthman OA, Rutherford GW. Optimal time for initiation of antiretroviral therapy in asymptomatic, HIV-infected, treatment-naive adults. Cochrane Database Syst Rev. 2010;2010(3):CD008272–008272.
HIV.gov. Global Statistics [Internet]. HIV.gov. 2020 [cited 2020 Aug 29]. https://www.hiv.gov/hiv-basics/overview/data-and-trends/global-statistics.
WHO. Consolidated guidelines on the use of antiretroviral drugs for treating. and preventing HIV infection [Internet]. Geneva, Switzerland: World Health Organization; 2016 [cited 2020 Aug 2] p. v. https://apps.who.int/iris/bitstream/handle/10665/208825/9789241549684_eng.pdf;jsessionid=E90C74EFE806AA7EB5273E885C28B7A1?sequence=1.
Grimsrud A, Lesosky M, Kalombo C, Bekker LG, Myer L. Implementation and Operational Research: Community-Based Adherence Clubs for the Management of Stable Antiretroviral Therapy Patients in Cape Town, South Africa: A Cohort Study. JAIDS J Acquir Immune Defic Syndr [Internet]. 2016;71(1). https://journals.lww.com/jaids/Fulltext/2016/01010/Implementation_and_Operational_Research_.18.aspx.
Columbia University. Rwanda Population -based HIV Impact Assessment (RPHIA): 2018–2019 [Internet]. ICAP. 2019 Dec [cited 2020 Oct 30] p. 6. https://phia.icap.columbia.edu/wp-content/uploads/2019/10/RPHIA-Summary-Sheet_Oct-2019.pdf.
Nsanzimana S, Remera E, Ribakare M, Burns T, Dludlu S, Mills EJ, et al. Phased implementation of spaced clinic visits for stable HIV-positive patients in Rwanda to support treat all. J Int AIDS Soc. 2017;20(Suppl 4):21635–21635.
Musengimana G, Umugisha JP, Habinshuti P, Anderson T, Mukesharurema G, Remera E, et al. Characteristics and clinical outcomes of patients presenting with advanced HIV disease in the treat all era: a retrospective cohort study from rural Rwanda. BMC Infect Dis. 2022;22(1):706.
Björn Södergård M, Halvarsson A, Sönnerborg MP, Tully. Åsa Kettis. The Degree of Readiness among a Population of HIV Infected Patients in Sweden. HIV Curr Res [Internet]. 2016 [cited 2020 Sep 21];1(2). https://www.longdom.org/open-access/the-degree-of-readiness-among-a-population-of-hiv-infected-patients-insweden-.pdf.
Shah GH, Etheredge GD, Nkuta LM, Waterfield KC, Ikhile O, Ditekemena J et al. Factors Associated with Retention of HIV patients on antiretroviral therapy in Care: evidence from Outpatient clinics in two provinces of the Democratic Republic of the Congo (DRC). Trop Med Infect Dis. 2022;7(9).
Anglemyer A, Rutherford GW, Easterbrook PJ, Horvath T, Vitória M, Jan M, et al. Early initiation of antiretroviral therapy in HIV-infected adults and adolescents: a systematic review. AIDS. 2014;28(Suppl 2):S105–18.
Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Antiretroviral therapy for the Prevention of HIV-1 transmission. N Engl J Med. 2016;375(9):830–9.
Shumbusho F, van Griensven J, Lowrance D, Turate I, Weaver MA, Price J, et al. Task shifting for scale-up of HIV Care: evaluation of Nurse-Centered Antiretroviral Treatment at Rural Health Centers in Rwanda. PLOS Med. 2009;6(10):e1000163.
Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334–40.
Sandelowski M. What’s in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77–84.
Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893–907.
Guest G, Bunce A, Johnson L. How many interviews are Enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59–82.
Rwanda Biomedical Center. National Guidelines for Prevention and Management fo HIV.Edition 2020 [Internet]. Rwanda Ministry of Helath. 2020. https://www.prepwatch.org/wp-content/uploads/2022/08/Rwanda-National-HIV-Guidelines-for-Prevention-Management-of-HIV-2020.pdf.
Ross J, Ingabire C, Umwiza F, Gasana J, Munyaneza A, Murenzi G, et al. How early is too early? Challenges in ART initiation and engaging in HIV care under treat all in Rwanda—A qualitative study. PLoS ONE. 2021;16(5):e0251645.
Baleeta K, Muhwezi A, Tumwesigye N, Kintu BN, Riese S, Byonanebye D, et al. Factors that influence the satisfaction of people living with HIV with differentiated antiretroviral therapy delivery models in East Central Uganda: a cross-sectional study. BMC Health Serv Res. 2023;23(1):127.
Leif Singer. Behaviour Change Modules [Internet]. MPH Online Module presented at: Online Class. 2019; Boston. http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories4.html.
Yang X, James TA, Brown MJ, Brown T, Zarsadias S, Zhang R, et al. Patterns of HIV Disclosure and its impact on the HIV Care Continuum among Black Men who have sex with men in South Carolina. Am J Mens Health. 2023;17(3):15579883231177981.
Ssali SN, Atuyambe L, Tumwine C, Segujja E, Nekesa N, Nannungi A, et al. Reasons for Disclosure of HIV Status by People Living with HIV/AIDS and in HIV Care in Uganda: an exploratory study. AIDS Patient Care STDs. 2010;24(10):675–81.
Joint United Nations Programme on HIV/AIDS (UNAIDS). Peer education and HIV/AIDS:Concepts, uses and challenges [Internet]. Geneva, Switzerland; 199AD [cited 2020 Mar 30] pp. 1–39. https://www.unaids.org/sites/default/files/media_asset/jc291-peereduc_en_0.pdf.
Prust ML, Banda CK, Callahan K, Nyirenda R, Chimbwandira F, Kalua T, et al. Patient and health worker experiences of differentiated models of care for stable HIV patients in Malawi: a qualitative study. PLoS ONE. 2018;13(7):e0196498.
Belay YA, Yitayal M, Atnafu A, Taye FA. Barriers and facilitators to the implementation and scale up of differentiated service delivery models for HIV treatment in Africa: a sco** review. BMC Health Serv Res. 2022;22(1):1431.
Knettel BA, Muhirwa A, Wanda L, Amiri I, Muiruri C, Fernandez KM, et al. Patient perspectives on the helpfulness of a community health worker program for HIV care engagement in Tanzania. AIDS Care. 2023;35(7):1014–21.
Nalini Asha Bigs(editor) authored by, Medley A, Kennedy C, O’Reilly K, Sweat M. Education and HIV/AIDS [Internet]. London: Continuum International Publishing Group; 2012 [cited 2020 Mar 30]. 160 p. https://www.ncbi.nlm.nih.gov/books/NBK77305/.
Gao X, Nau DP, Rosenbluth SA, Scott V, Woodward C. The relationship of disease severity, health beliefs and medication adherence among HIV patients. AIDS Care. 2020;12(4):387–98.
Genberg BL, Lee Y, Rogers WH, Willey C, Wilson IB. Stages of change for adherence to antiretroviral medications. AIDS Patient Care STDs. 2013;27(10):567–72.
Zakumumpa H, Rujumba J, Kwiringira J, Katureebe C, Spicer N. Understanding implementation barriers in the national scale-up of differentiated ART delivery in Uganda. BMC Health Serv Res. 2020;20(1):222.
Long L, Kuchukhidze S, Pascoe S, Nichols BE, Fox MP, Cele R, et al. Retention in care and viral suppression in differentiated service delivery models for HIV treatment delivery in sub-saharan Africa: a rapid systematic review. J Int AIDS Soc. 2020;23(11):e25640.
Bochner AF, Meacham E, Mhungu N, Manyanga P, Petracca F, Muserere C, et al. The rollout of Community ART Refill groups in Zimbabwe: a qualitative evaluation. J Int AIDS Soc. 2019;22(8):e25393.
Julie Hubbard K, Phiri C, Moucheraud K, McBride A, Bardon K, Balakasi, et al. A qualitative Assessment of Provider and Client experiences with 3- and 6-Month dispensing intervals of antiretroviral therapy in Malawi. Glob Health Sci Pract. 2020;8(1):18.
Youngji Jo L, Jamieson B, Phiri A, Grimsrud M, Mwansa H, Shakwelele et al. Factors associated with attrition from HIV treatment after enrollment in a differentiated service delivery model: a cohort analysis of routine care in Zambia. medRxiv. 2022;2022.05.30.22275759.
Aung S, Hardy N, Chrysanthopoulou S, Htun N, Kyaw A, Tun MS, et al. Evaluation of peer-to-peer HIV counseling in Myanmar: a measure of knowledge, adherence, and barriers. AIDS Care. 2022;34(6):762–70.
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Sebeza, J., Muiruri, C., Riedel, D.J. et al. Is the Differentiated Service Delivery Model Suited to the Needs of People Living with HIV in Rwanda?. AIDS Behav (2024). https://doi.org/10.1007/s10461-024-04376-1
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DOI: https://doi.org/10.1007/s10461-024-04376-1