Background and rationale {6a}
DSD, viral suppression, HIV better, HIV is a client-centered approach, chronic disease
CHRONIC DISEASE
HIV care programs have evolved into a chronic disease care model in South Africa, where eight million people are living with HIV [Differentiated service delivery (DSD), also known as differentiated care, for HIV is a client-centered approach that simplifies and adapts HIV services across the HIV care continuum, in ways that both serve the needs of people living with HIV better and reduce unnecessary burdens on the health system [DSD models have been implemented across sub-Saharan Africa that differ from standard clinic-based care and are targeted to stable patients (i.e., clients with suppressed viral loads) on ART [These DSD models differ in the intensity of service provision and, consequently, in the resources required. For example, lottery incentives are low cost to implement but have a short-term effect increasing ART initiation but not long-term viral suppression [The simplification and client-centeredness of DSD approaches could be adapted to help those who are struggling instead of succeeding. As HIV services, specifically supplying ART and conducting monitoring, mature, the most pressing need is for clients to access ART over their lifetimes—i.e., services to support lifelong retention. However, 5-year retention in care in South Africa is 60% [We and others found that DSD, as currently implemented, often costs effectively the same as standard models [“Right-sizing” DSD to fit client needs and provider services so that more intensive services reach clients that would benefit from simplification and client-centered approachesA unique opportunity exists to evaluate the impact of strategies to reengage and retain people living with HIV with detectable viral load and/or otherwise not engaged in care, specifically by providing enhanced services to clients with detectable viral load and/or who are not engaged in care. To address gaps in care, the South African National Department of Health (NDOH) clinics are rolling out interventions to increase viral suppression and retention in care. For example, Médecins Sans Frontières (MSF) has piloted a “Welcome Back” service at HIV clinics in the Western Cape to reengage clients in care who have previously been lost to follow-up or who have detectable viral load and this service is being further refined and adapted at other clinics. The Welcome Back service has three pillars: (1) identification and linkage, (2) medical support including care for advanced HIV, and (3) psychological support including adherence support. Working with MSF, we will adapt their clinic staff training and client materials to support best clinic practices. In the proposed study, we will work with clinic teams to implement the MSF Welcome Back services and other evidence-based clinic interventions, specifically adequate stock of ART, fast-track ART, time for clients, and kind providers which have been associated with higher retention in care [DSD approaches work for persons not engaged in care. Building on best clinic practices, lottery incentives shorten time to ART initiation [