Reaching Global HIV Goals Will Take Creativity.

December 1 is World AIDS Day, a good time to take stock of how far HIV/AIDS care and prevention have come, and the new challenges we now face. Of the estimated 38 million people living with HIV globally, more than two thirds—some 26 million—reside in sub-Saharan Africa. Africa also accounts for nearly 17 million of the world’s 23 million patients on antiretroviral therapy (ART) for HIV.

As researchers focusing on the epidemiology and economics of the HIV response in Africa, we have seen particularly striking changes in the last decade and a half in the way that low- and middle-income countries have taken on the challenge of long-term treatment for those living with HIV—an ongoing struggle that is giving rise to creative new strategies.

When large scale, publicly-funded HIV treatment delivery became a reality in many low-resource settings in 2004 (at the initiative of the international community and with unprecedented financial support from the United States and others), global guidance was to limit treatment eligibility to those with advanced disease, as measured by their CD4 count (a measure of immune function) or the advent of an “AIDS-defining” illness such as tuberculosis or pneumocystis pneumonia. Over time, however, as research—including ours—demonstrated the benefits of earlier treatment initiation to both HIV-positive individuals and to their uninfected partners, patients became eligible for lifesaving treatment earlier, before they had become dangerously ill. In most of the world, “universal treatment” is now the norm, with those testing positive for HIV offered immediate access to ART.

Universal treatment accessibility has reversed previous trends in AIDS mortality, raising life expectancy in some countries by more than a decade (after the freefall caused by HIV before treatment was available) and generating one of the greatest public health successes in history. It is also a critical component of efforts to achieve HIV epidemic control, by reducing, if not eliminating, transmission of HIV through individuals successfully suppressing their viral loads by adhering to ART.

At the same time, universal treatment has placed tremendous pressure on already-strained healthcare systems in lower- and middle-income countries, such as those in southern Africa, where we work. Offering free, lifelong treatment to millions of patients with an insufficient healthcare workforce and scattered and poorly-maintained infrastructure imposes what may be an unsustainable burden on healthcare systems, national budgets, and patients and their families. One result is all-day waiting times at clinics for HIV patients to refill medication prescriptions; another is high rates of attrition from care among patients who cannot afford monthly transport costs to distant clinics.

In response to this burden, many countries have begun to implement what are widely known as “differentiated service delivery” (DSD) models for HIV care. These models contrast with what is now referred to as “conventional” care, in which patients typically receive all services from established clinics, which they are required to visit as often as monthly for medication refills and clinical care. DSD models reflect the realization that this one-size-fits-all approach to delivering ART is not optimal for either patients or providers. These models tailor treatment delivery to the needs of different groups of patients, with the goal of improved patient outcomes such as lower costs and better retention in care, and increases in clinic efficiency, allowing existing providers to manage more patients and/or provide better quality care to those who need it.

In DSD models, patients who are considered “stable on treatment”—those who have been on treatment long enough to achieve viral suppression and show sustained adherence—can be managed less intensively than newly-initiated patients, those with advanced disease or virological failure, and those considered at high risk for loss to follow-up. For stable patients, DSD models offer fewer clinic visits, more convenient service delivery locations, and greater reliance on community support. Examples of these models include out-of-clinic medication pickup points so patients can avoid very long clinic pharmacy queues, and multi-month dispensing of medications so that patients do not have to make monthly clinic visits just for medication refills.

There are also community-based “adherence clubs” that offer groups of patients monitoring, medication, and social support closer to home. Patients meet in small groups with a nurse or a counsellor and talk about any issues they have with treatment or adherence to treatment and share their experiences. Medication can then be dispensed to the group, avoiding the need to wait in long pharmacy queues and patients then only need to be seen by a clinician once a year.

While evidence on the impacts of DSD models remains scarce, what does exist suggests that these “lower intensity” models work as well as conventional care in terms of patient outcomes, and are very well-liked by patients, saving them substantial time and money and providing much-needed flexibility. Our recent study in the journal PLOS Medicine found that patients had positive things to say about adherence clubs, and that patients in adherence clubs had slightly better retention in care compared to those in usual care and similar viral suppression.

This is great news. But it isn’t surprising that stable patients remain stable when you make it easier for them to access care. It is the patients who do not qualify for less intensive models of care who may need them most. Abundant evidence points to logistical challenges such as transportation fares, inflexible work schedules, and all-day waiting times at clinics as some of the major reasons patients stop taking ART, especially during their first few months on treatment. DSD models are designed to reduce just these barriers, but current requirements for DSD model eligibility, in both global and national guidelines, exclude the patients who are most hampered by such barriers.

Now that there is some evidence that we can serve stable patients with less intensive models, the next push will be to address the needs of new, unsuppressed, and advanced disease patients. Most existing interventions for “non-stable” patients actually increase patient interactions with the healthcare system—more clinic visits, more counseling—rather than making treatment easier for such patients.

We and others are starting to envision models that address patients’ complicated lives and lack of resources from the moment of treatment initiation, rather than waiting until a significant number of people have already been lost from care before allowing them access to less intensive models. We are also developing behavioral interventions to empower and motivate patients from Day 1 of treatment. To do this, we work closely with our partner organization in South Africa, the Health Economics and Epidemiology Research Office (HE²RO). HE²RO is a division of Wits University in Johannesburg, founded some fifteen years ago as a collaboration between Wits and Boston University. With HE²RO and other collaborators, we are evaluating the implementation and outcomes of DSD models in South Africa, Zambia, Malawi, and other African countries.

We don’t know what the future will hold for HIV care. Even if a vaccine is not on the horizon, changes in treatment such as the development of long-term injectable regimens that reduce the burden of care-seeking may make sustaining lifelong treatment easier and more tolerable to patients. But until such changes come, national HIV programs will need to adopt creative approaches to healthcare delivery to meet the challenges of provision of care to large populations. We and our colleagues, both at BUSPH and globally, are now focused on developing and evaluating such approaches.

Matthew Fox is a professor of epidemiology and global health at the Boston University School of Public Health. Sydney Rosen is a research professor of global health at the Boston University School of Public Health and co-director of the Health Economics and Epidemiology Research Office (HE²RO) of the University of the Witwatersrand in Johannesburg, South Africa.