#BetterHIVcare: Differentiated models of care across the HIV continuum
While most countries have embraced efforts to end AIDS by 2020 through achievement of the global 90-90-90 targets, set forth by the Joint United Nations Programme on HIV/AIDS (UNAIDS), implementing the most effective strategies is the hard part and places a significant burden on health systems. Although nations and their development partners are scaling up efforts to end AIDS, international and domestic funding is not increasing proportionately. Innovative strategies must be created and used to sustain health systems, support clients and ensure that clients stay in treatment over the long term.
One such strategy is known as differentiated models of care — service delivery that is tailored to the unique needs of clients across the continuum of prevention, care and treatment. This approach fosters efficiency at the health facility and community levels, allowing quality of care to be maintained with existing human and financial resources. It also makes obtaining services easier and more convenient for clients, which promotes their uptake of and retention in those services.
FHI 360 is applying differentiated models of care in Africa to improve service delivery to specific groups of people, including key populations (men who have sex with men, sex workers, transgender people, and people who inject drugs), pregnant women, orphans and vulnerable children, and youth.
Differentiated models of care provide people with options around each of these factors (also see infographic):
- When medication is collected or delivered
- Where care and treatment are obtained
- Who delivers the services
- Which services are needed
Five steps for differentiated models of care are:
- Engage stakeholders to foster buy-in and ensure the model is appropriate
- Assess the context, including the policy environment, the supply chain and the needed human resources
- Plan implementation from both the supply and demand perspectives
- Roll out the model
- Conduct monitoring and evaluation to ensure the model is effective, making adjustments as needed
FHI 360 has expanded HIV testing in several African countries using the differentiated models of care approach and the five steps.
In South Africa, FHI 360 has integrated HIV services into programs for orphans and vulnerable children and youth — programs that have traditionally focused on social rather than health issues. We use these programs as an entry point, building trust and strong relationships through a holistic case management approach in which each person’s needs are assessed and met with customized care and services. This fosters a nurturing environment for the entire family while addressing key structural factors, such as economic vulnerability and gender norms. One year after implementing an intervention that included intensive training and mentoring to community care workers and a testing partner to assist with home-based testing, five local partners tested 10 times more clients than they had the previous year.
Private health facilities serve more than 60 percent of Nigerians. However, in 2012, only 40 percent of these facilities offered services to prevent mother-to-child transmission of HIV, and only 10 percent of these facilities met national standards for delivery of these services.* FHI 360 supported expansion of these prevention services, using a health facility rapid assessment tool to guide our development of costed scale-up plans, tailor trainings, activate sites and provide ongoing site mentorship. Our efforts boosted the rates at which facilities provided these services from 8 percent to 61 percent over two years. This increased the number of pregnant women with access to HIV testing by 246 percent, and it increased their access to antiretroviral therapy by 152 percent.
FHI 360 achieved remarkable results in Zimbabwe by using a sexual network testing model. First, geographic information system (GIS) mapping and geographical targeting supported our identification of under-reached populations. After clients tested HIV-positive, they provided consent for partner notification, and we delivered household testing to their sexual contacts and family members. Yield rates rose from 8 percent to 40 percent.
New HIV infections are increasing among adolescents ages 15 to 24, which is the only age group in Africa in which deaths are not decreasing. In Kenya, FHI 360 has adapted the entire continuum of prevention, treatment and care specifically for adolescents living with HIV. This includes providing treatment literacy (explaining to clients what their treatment entails and how to manage it); establishing community adherence groups to give patients a choice to refill medications at a health facility or elsewhere, such as a community center; and supporting patients with referral coordinators and case managers. Adolescent retention in care has subsequently increased from 57 percent to 72 percent.
Differentiated models of care are yielding promising results, and FHI 360’s experience demonstrates that existing structures and resources can be leveraged to provide population-specific care and support. More remains to be done, but consistent sharing of best practices and lessons learned will be critical to achieving the 90-90-90 targets.
For more on differentiated models of care, visit FHI 360’s online synopsis.
*Kasonde P. Eliminating mother-to-child transmission of HIV: Case study from Nigeria and Zambia. Presented at Differentiated Models of Care across the HIV Continuum: Insights and Innovations, 2017 June 12, Durban, South Africa.
Photo credit: Jessica Scranton/FHI 360