Differentiated Services Delivery Model and its associated outcomes among people living with HIV in Tanzania: A cross-sectional study

Background: Differentiated Service Delivery Model (DSDM) is now increasingly recognised as an important and sustainable approach that could contribute significantly towards the UNAIDS 90-90-90 by 2020 and 95-95-95 by 2030 targets and ultimately an AIDS-free generation. It is a strategy in use to promote retention in HIV care and/or ART adherence. Thus, this study aimed to determine the outcomes of DSDM among people living with HIV in Tanzania.

Methods: A Cross-sectional analytical design was conducted in nine regions of Tanzania with low, moderate and high HIV prevalence in the period from January to March 2020. We employed both quantitative and qualitative methods for data collection and analysis. We conducted record reviews and in-depth interviews with key informants at national and facility levels. Their data was summarised and arranged in sub-themes and then analysed according to the specific objectives using Thematic Analysis. We further conducted a bivariate analysis using Chi-Square to assess the association between each outcome and explanatory variable. Unadjusted and adjusted analysis was conducted to determine predictors of unfavourable outcomes using binary logistics and Cox regression models.

Results: Data was collected from 50 health facilities comprising 15 (30.0%) hospitals, 22 (44.0%) health centres and 13 (26.0%) dispensaries. Record reviews were for different outcomes as follows; Mis-categorization (13,056 records), Missed appointments (62,222 records), Advanced HIV disease (29,995 records), and Attrition (62,222 records). Among the 320 unstable clients, the miscategorisation rate significantly decreased after DSDM's introduction, from 63% to 36% (p < 0.001). After the introduction of DSDM, more clients missed their appointments compared to the period before the introduction of DSDM (1.7% vs 0.8% respectively). Missed appointments were associated with an urban setting ( AOR=1.1; 95%CI 1.1-1.2) and older age of 50 years and more (AOR=1.2; 95%CI 1.1-1.4) compared to a rural setting and younger age of less than 15 years respectively. Furthermore, DSDM led to a decrease (from 56.3% to 48.6%) of those with advanced WHO stage (WHO clinical stage 3 or 4) among the first-time testers. Attrition among the clients was higher after the introduction of DSDM compared to that before DSDM (ARR=1.1; 95%CI 1.04-1.2). Contributors to attrition were those related to individuals and institutions, including beliefs in faith healing, fear of stigma and wrong interpretation of viral load monitoring results.

Conclusion: Decentralized Community-based ART model is a promising entry point to improved HIV/AIDS service delivery. Strategies are needed to harmonise the comprehensiveness and quality of services across facilities providing HIV services.

Keywords: DSDM, Adherence, HIV/AIDS, ART, outcome