“The amount of time we spend at the health facility in the queues – a queue for triage, a queue for the nurse, a queue at the pharmacy and a queue for the labs – it's too much time. I want to come to the facility only twice a year... I have a life to live.”
– Patricia Asero Achieng, person living with HIV in Kenya
This week, the European HIV community gathered in Glasgow, Scotland to discuss therapeutic strategies and research in HIV. The focus: client-centred care. It’s not hard to understand why when globally one in seven new clients on antiretroviral treatment (ART) is lost to care after only one year of starting treatment.
ART is one of the most effective tools available in preventing transmission and controlling the virus so that people living with HIV (PLHIV) can lead healthy and productive lives. However, despite the progress made in the last five years – doubling the number of people on ART – there are still only 17 million people accessing ART out of the 37 million PLHIV. It is critical that when a person is diagnosed with HIV they can access ART immediately and remain on treatment for the rest of their lives, yet this is a massive challenge that we continue to face.
The delivery gaps in ART services largely exist because the current “one-size-fits-all” ART approach does not meet individual needs. As Linda-Gail Bekker, President of the International AIDS Society (IAS), recently emphasized, we have the tools to reverse the AIDS epidemic but we need focused and locally tailored prevention and treatment services to fill in the gaps. We need a client-centred, differentiated care approach.
Differentiated care is a client-centred approach that simplifies and adapts HIV services to both serve the needs of PLHIV whilst reducing burdens on the health system. So how exactly does this approach deliver differently and what is the specific impact?
Provide PLHIV quality and adapted HIV services when, where and how they want it
Among PLHIV, some have been on treatment for many years and are virally supressed. For these clinically “stable” clients, it does not make sense to come every month to a crowded health facility to collect their ART refills. Others may have challenges adhering to their treatment or the HIV treatment they are taking may not be working or they are experiencing other co-morbidities and co-infections. These clients require increased clinical support.
Under a differentiated model of ART delivery, “stable” clients can have less frequent ART refills and clinical consultations, so that “unstable” clients have increased access to clinical staff and appropriate services. As a result, this gives many benefits to clients: quicker and sustained access to life-saving medicines, less time waiting in and travelling to clinics, fewer out-of-pocket travel expenses, and less time off work to attend clinics.
Improve health system efficiencies and outcomes
To avert 21 million AIDS-related deaths and 28 million new infections by 2030 with the World Health Organization’s (WHO) “treat all” recommendation, health systems now face considerable challenges. They need to retain the capacity to simultaneously respond to the needs of PLHIV currently on treatment, those undiagnosed, and prevent new infections. Innovative solutions, such as differentiated care, are urgently needed for health systems to mobilize and re-allocate already stretched resources. With only 60% of PLHIV who know their status, 46% of PLHIV on treatment, and only 38% of PLHIV virally suppressed, we haven’t even reached the halfway mark to achieving the UNAIDS 90-90-90 targets (90% diagnosed, 90% of those diagnosed on treatment, and 90% of those on treatment virally suppressed by 2020). However, data from sites where differentiated ART delivery is implemented show improved retention and adherence rates, which could help countries stay on-track to reach the 90-90-90 targets. Countries are beginning to realize this potential - South Africa, Kenya, Zimbabwe and Swaziland have now included differentiated ART delivery into their national guidelines.
Closing the treatment gap will not be sufficient to end the AIDS epidemic. There is a significant need to scale up HIV treatment in parallel to prevention efforts, particularly among priority populations that are underserved in some countries. The Decision Framework for ART Delivery, is a roadmap to help us get there. By putting people at the centre of care, we can better reach the individuals who need ART the most, increase retention, and maintain viral suppression.