Are HIV Treatment Clients Offered a Choice of Differentiated Service Delivery Models? Evidence from Malawi, South Africa, and Zambia

Idah Mokhele,1 Vinolia Ntjikelane,1 Nancy A Scott,2 Jeanette L Kaiser,2 Allison Juntunen Morgan,2 Amy Huber,1 Nomcebo Oratile Mokgethi,1 Timothy Henry Tchereni,3 Wyness Phiri,3 Aniset Kamanga,4 Prudence Michelo Haimbe,4 Priscilla Lumano-Mulenga,5 Rose Kolola Nyirenda,6 Sophie JS Pascoe,1 Sydney Rosen1,2 1Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; 2Boston University School of Public Health, Boston, MA, USA; 3Clinton Health Access Initiative, Lilongwe, Malawi; 4Clinton Health Access Initiative, Lusaka, Zambia; 5Ministry of Health, Lusaka, Zambia; 6Ministry of Health, Lilongwe, MalawiCorrespondence: Idah Mokhele, Health Economics and Epidemiology Research Office, Building C, First Floor, Sunnyside Office Park, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa, Tel +27 10 001 7930, Email [email protected]: Differentiated service delivery (DSD) models for antiretroviral therapy (ART) for HIV aim to increase patient-centeredness, a concept that incorporates patient choice of service delivery options. We explored choice in DSD model enrollment at 42 public sector clinics in Malawi, South Africa, and Zambia.Methods: From 09/2022-05/2023, we surveyed people receiving HIV treatment to ask if they had a choice about DSD model enrollment and healthcare providers about their practices in offering choice. We estimated risk differences for ART clients’ self-reported offer of choice and report risk differences. We thematically analyzed open-ended questions and report key themes.Results: We enrolled 1049 people receiving HIV treatment (Malawi 409, South Africa 362, Zambia 278) and 404 providers (Malawi 110, South Africa 175, Zambia 119). The proportion of study participants indicating that they had been offered a choice ranged from 4% in Malawi to 17% in Zambia to 47% in South Africa. Over 90% of people receiving HIV treatment in all three countries reported that they were happy to be enrolled in their current DSD model. Participants from urban (ARD 0.94 [0.90– 0.99]) and medium-volume facilities (2000– 4000 ART clients, 0.91 [0.84– 0.98]) were slightly less likely to be offered DSD enrollment. Participants in community-based models 1.21 [1.12– 1.30] and those satisfied with their current model 1.06 [1.01– 1.13] were more likely to be offered a choice. Among providers, 64% in Malawi, 80% in South Africa, and 59% in Zambia said they offered clients the choice to enroll in DSD or remain in conventional care.Conclusion: As of 2023, relatively few people receiving HIV treatment in Malawi, South Africa, and Zambia reported being offered a choice about enrolling in a DSD model, despite most providers reporting offering such a choice. The value of patient choice in improving clinical outcomes and satisfaction should be explored further.Plain-Language Summary: Differentiated service delivery (DSD) models for antiretroviral therapy (ART) enhance patient-centeredness by offering choices in service delivery options. We explored choice in DSD model enrollment at 42 public sector clinics in Malawi, South Africa, and Zambia. From 09/2022-05/2023, we interviewed people receiving HIV treatment and healthcare providers, asking participants whether they had a choice about DSD model enrollment and whether providers offered this choice to their patients. We analyzed the data to identify differences in how people receiving HIV treatment reported being offered a choice. 1049 people receiving HIV treatment participated: 409 from Malawi, 362 from South Africa, and 278 from Zambia, alongside 404 providers (110 in Malawi, 175 in South Africa, and 119 in Zambia). 4% in Malawi, 17% in Zambia, and 47% in South Africa reported being offered a choice to enroll in a DSD model. Few actively sought to join a DSD mode (Malawi 10%, South Africa 19%, and Zambia 13%)—but many consented to enroll even when not explicitly offered (Malawi 66%, South Africa 80%, Zambia 59%). Over 90% were happy with their current DSD model. Among providers, 64% in Malawi, 80% in South Africa, and 59% in Zambia reported offering patients the choice to enrol in a DSD model or remain in conventional care. Most people receiving HIV treatment in our study did not report being offered a choice to join a DSD model despite providers claiming they offered one. Further research is needed to understand how offering choices could improve health outcomes and satisfaction with care.Keywords: antiretroviral therapy, differentiated service delivery, client choice, client-centered