Differentiated models of antiretroviral treatment (ART) delivery allow for increased coverage and/or accessibility of ART by providing multiple options for collecting medication. Community-level differentiated models bring services closer to where people live and work. Findings were compiled into three country report and a cross-case findings report. Five key lessons were learned: 1. Client and provider education facilitates implementation 2. Information systems are vital to success 3. Buy-in is required at multiple levles 4. Client grouping impacts success and sustainability 5. Build mechanisms to address stigma Overall differentiated models present a major opportunity to increase access to ART, reduce provider workload, and improve client agency for self care. Also continuing to build upon the existing knowledge base will help countries refine and expand these models. Presented at the Fifth Global Symposium on Health Systems Research in Liverpool in October by Nikki Davis

1. Increasing Access to ART through the
Implementation of Differentiated Models
of Distribution: Lessons Learned from a
Three-Country Study
Nikki Davis
JSI Research & Training Institute, Inc.

2. Background
• WHO “Treat All” Approach
– Pressure on low- and middle-income countries to
initiate more people on antiretroviral treatment
(ART)
– Increased strain on already overburdened health
systems
• Response
– Decentralized and differentiated models of ART
distribution

3. Differentiated Models of
ART Delivery
• Allow for increased coverage and/or
accessibility of ART by providing multiple
options for collecting medication
• Typically target clinically stable clients
• Have been implemented at both the
health facility and community levels
• Often involve multi-month dispensing of
ART and reduced frequency of visits to the
health facility

4. Community Models
• Community-level differentiated models
bring services closer to where people live
and work
• Examples of these models include:
– Community Adherence Groups
– Community Distribution Points
– Outreach

5. Gaps in Knowledge
• Limited information on the learnings
associated with the implementation and
scaling of these models that could:
– Help countries refine and expand models
– Increase coverage to sub-populations

6. Study Design
• Qualitative study
• Three country
contexts
• Multiple perspectives
Respondent Type
Total
Participated
High-level stakeholders and policy
influencers/makers
23
Program designers, implementers,
providers
72
Model beneficiaries 78

7. Analysis
• Nvivo11 Software
• Synthesis of major themes per country
• Findings compiled into three country
reports and a cross-case findings report

8. Five Key Lessons
Learned

9. Client and Provider Education
Facilitates Implementation
• Comprehensive provider and client orientation to
distribution models deemed critical
– Prepares providers to drive demand for models
– Enables clients to make informed decision on which
model best fits their needs/desires
– Allows both clients and providers to adjust to and
prepare for less frequent clinic visits
– Facilitates client empowerment to self-manage their
care

10. Information Systems Are Vital
to Success
• Robust information systems facilitate long-term
success by
– Identifying eligible clients
– Tracking and monitoring client appointments and ART
pick-ups, and identifying missed appointments
– Maintaining linkages between clients and the health
system
– Helping to ensure adequate and consistent supply of
medication

11. Buy-in Is Required At
Multiple Levels
• Implementation at the community level
can be complex and requires sensitization
and buy-in
– Clients
– Providers
– Community
• Proof of concept facilitates buy-in for clients and
providers

12. Client Grouping Impacts
Success and Sustainability
• Group-based models were found to need
special considerations in terms of composition
– Groups comprised of “like” people (e.g., same
gender, age groups) tended to be more successful
– Voluntary formation of groups facilitated better
cohesion than having members assigned

13. Build Mechanisms to
Address Stigma
• Stigma is a major concern with community-level
models
– Fear of unintended disclosure
• Modes of addressing potential stigma should be
context-specific and may include but not limited to
the following:
– Finding appropriate meeting and distribution space within
the community
– Ensuring peer support
– Combining ART with distribution of other chronic
medications

14. • Differentiated models present a major
opportunity to increase access to ART,
reduce provider workload, and improve
client agency for self-care
• Continuing to build upon the existing
knowledge base will help countries refine
and expand these models
Translation of Findings

15. Acknowledgments
• Sabrina Eagan (JSI)
• Malia Duffy (JSI)
• Melissa Sharer (JSI)
• Ugochukwu Amanyeiwe (USAID)
• Ndinda Makina (JSI)
• Clara Haruzivishe (University of Zimbabwe)
• Milly Katana (NAFOPHANU)

16. Thank You!
This publication is made possible by the generous support of the American people through the U.S. President’s
Emergency Plan for AIDS Relief (PEPFAR) with the United States Agency for International Development (USAID) under
the Cooperative Agreement Strengthening High Impact Interventions for an AIDS-free Generation, number AID-OAA-A-
14-00046. The information provided does not necessarily reflect the views of USAID, PEPFAR, or the U.S. Government.