National Policies

Cameroon

In 2017, the Ministry of Public Health in Cameroon published Operational Guidelines for the Implementation of the Test and Treat Strategy in Cameroon.  These guidelines detail differentiated HIV services for clinically stable clients, including three monthly ART dispensing (3MMD) and clinical monitoring.

Cote D’Ivoire

On 25 March 2020, the Cote d’Ivoire Ministry of Public Health and Hygiene, with the National AIDS Control Programme, published a contingency plan for the programme in the context of the COVID-19 pandemic. It details two scenarios for the continuation of the programme, depending on the stage of the pandemic.

Democratic Republic of the Congo (DRC)

In 2018, the National HIV/AIDS and STI Control Programme of the DRC Ministry of Health developed both an operational plan and an operational manual to implement differentiated service delivery (DSD) for people living with HIV. It outlines different context- and population-specific models, including community antiretroviral therapy (ART) distribution points, and recommends three- to six-month ART refills for stable clients. The operational manual also includes guidance for service providers on HIV/TB service integration.

Eswatini

On 22 April 2020, the Eswatini Director of Health Services published a memorandum, Guidance on Provision of Chronic Care During the COVID-19 Pandemic, which informs the management of clients with chronic conditions, including HIV and non-communicable diseases. HIV-specific guidance differentiates care for adults, children and perinatal women and includes information on contraception and viral load monitoring. In April 2020, the Eswatini Ministry of Health released the Community Commodity Distribution Concept Note, which proposes the use of a hybrid of its current DSD models for commodity distribution. The aim is to enable sustainable access to a broad spectrum of HIV-related treatments while reducing risk of COVID-19 exposure for people living with HIV and other health service users.

The Eswatini National AIDS Programme’s National Policy Guidelines for Community-Centred Models of ART Service Delivery (June 2016) recognizes the need for differentiation throughout the treatment pathway and provides specific guidance for management of stable clients. The guidelines are accompanied by a set of standard operating procedures (SOPs), published in 2018, including SOPs for community-centred models of HIV testing and ART service delivery for key populations.

Ethiopia

The Ethiopian Ministry of Health published Interim Guidance for Management of People Living with HIV (PLHIV) in the Context of COVID-19 Outbreak in Ethiopia in early March 2020. This document includes specific facility-level guidance on differentiated services for ART provision, as well as information on mitigation of the spread of COVID-19 in communities affected by HIV.

In February 2017, Ethiopia released the revised National Guidelines for Comprehensive HIV Prevention, Care and Treatment, with a section (5.1) on “differentiated care”. The guidelines recommend appointment spacing as one of the differentiated ART delivery models, as well as referring stable clients to receive six-monthly clinical visits and medication refills.

Ghana

In December 2017, the Ghana National AIDS Control Programme launched Differentiated service delivery for HIV in Ghana: An Operational Manual, which was developed with several collaborators. The manual focuses on the “how” of differentiated HIV care and includes differentiated HIV testing services, differentiated ART initiation and differentiated ART delivery (including for clients with high viral load and clients with co-infections and co-morbidities). Throughout the document, considerations are provided for specific populations, including pregnant and breastfeeding women, children and adolescents, and key populations.

Guinea

In 2019, the Guinea Ministry of Health and the National HIV/AIDS and Hepatitis Programme developed an implementation guide for six-monthly (6MMD) antiretroviral therapy refills, locally known as “Rendez-vous à six mois”.

India

On 23 March 2020, the Indian Ministry of Health and Family Welfare released its Guidance Note for Persons engaged in HIV/AIDS response under National AIDS Control Programme in view of the COVID-19 scenario. In addition to general COVID-19 precautions for the programme facilities, the note gives specific guidance on ART dispensation, including multi-month and community dispensing. It also mentions commodity distribution within specific vulnerable groups.

Kenya

In March 2020, the Kenyan Ministry of Health released a circular titled COVID-19 Guidance on Comprehensive HIV Service Delivery. The document makes specific recommendations for ensuring continuity of HIV testing and ART services throughout the pandemic, including three monthly dispensation (3MMD) and promotion of flexible ART delivery models, such as community ART group distribution.

Since 2016, the Kenyan Ministry of Health, through the National AIDS & STI Control Programme (NASCOP), has included provision for differentiated service delivery (DSD) in national guidelines. New Guidelines on Use of Antiretroviral Drugs for Treating and Preventing HIV in Kenya were launched in 2018, including guidance on DSD for clients who have advanced disease and those who are clinically well. To accompany the guidelines and practical handbook, NASCOP released Differentiated Care: Operational Guide in January 2017. 

Lesotho

The Lesotho National HIV and AIDS Strategic Plan 2018/19 – 2022/23 (NSP) is described as embodying a shift from an intervention focused, to a people-centred HIV response.  Differentiated service delivery (DSD) is central to this NSP, with DSD models featured throughout the cascade of HIV prevention, testing and treatment services.

Liberia

In May 2020, the Liberian National AIDS and STI Control Program (NACP) published a standard operating procedure (SOP) on implementation of six monthly ART dispensation (6MMD) during the COVID-19 pandemic.  The document is to be used in conjunction with the Facility Assessment and Preparation Tool and details eligibility criteria for the 6MMD programme.  

On 25 March 2020, the Liberian Ministry of Health NACP published Interim Guidance for COVID-19 for all Persons with HIV, which includes recommendations for multi-month dispensation of antiretroviral therapies and telephonic feedback of viral load results.

Malawi

The Malawian Ministry of Health published COVID-19 Guidance for HIV Services (2nd Edition) on 17 April 2020. This identifies which existing HIV services should continue and which should be suspended. It also details additional measures, including six monthly dispensing (6MMD) of certain ART regimens.

Malawi’s 2016 Guidelines on the Clinical Management of HIV in Children and Adults (3rd edition) include differentiated ART delivery for adults and children. 

Mozambique

On 27 March 2020, the Mozambique Directorate of Public Health released a circular on HIV service delivery in the context of COVID-19. This circular contains guidance on changes within HIV prevention, testing and treatment service packages, including expansion of three-monthly ART refills and adaptations of Mozambique’s community ART groups to support physical distancing.

In 2018, the Ministry of Health in Mozambique released guidance on differentiated service delivery with two modules. The first focuses on differentiated prevention and testing services and the second on differentiated antiretroviral therapy (ART) delivery, including community ART groups and family-centred approaches. This guidance complements the 2015 document on community adherence and support group strategies.

Namibia

In 2019, the Ministry of Health and Social Services in Namibia released the sixth edition of their National Guidelines for Antiretroviral Therapy to align with new recommendations from the World Health Organization. Chapter 9 on ‘Differentiated Services(sic) Delivery’ outlines various facility-based and out-of-facility models as well as ART multi-month dispensing guidelines.

Nigeria

In 2016, the Federal Ministry of Health in Nigeria released revised national guidelines for HIV prevention, treatment and care. In addition to recommending that all people living with HIV initiate ART, the guidelines included a chapter on service delivery. In Chapter 9, four broad categories of people living with HIV are outlined as per World Health Organization (WHO) recommendations. A specific package of care is described for clinically stable clients, including three-monthly clinical consultations, three-monthly (3MMD) ART refills and community ART delivery models.

Rwanda

Rwanda’s National Guidelines for Prevention and Management of HIV and STIs were revised in 2016 and included section 10 on a differentiated model for ART delivery for stable patients. Stable patients are eligible to receive three-monthly (3MMD) refills directly from a pharmacy and six-monthly clinical consultations. The policy outlines eligibility criteria for these models and explicitly states that all stable patients from key populations are also eligible.

Sierra Leone

In May 2020, the National HIV/AIDS Control Programme published COVID-19 guidance on comprehensive HIV service delivery. It includes recommendations for same-day ART initiation and possible multi-month dispensing of ART, drug supply logistics in the event of a complete lockdown and details on suspension of outreach services.

In May 2018, the Ministry of Health and Sanitation in Sierra Leone, with support from UNAIDS, set out its country guidance on differentiated service delivery in the Guide of Differentiated care model in Sierra Leone: Who feels it knows. The guidance covers the continuum of care from HIV testing to ART delivery for stable clients and highlights differentiation for men, adolescents and key populations. It specifically defines a stable child and differentiated ART delivery models for children and adolescents. It also includes differentiated viral load testing approaches. 

South Africa

The South African National Department of Health has published two COVID-19-specific guidance documents related to HIV. Guidance to Implementing Partners Regarding Managing Clients on Pre-Exposure Prophylaxis (PrEP) during State of Emergency (sic) COVID-19 (26 March 2020) details procedures for managing new and existing PrEP clients during the country’s COVID-19 lockdown. Response to reduce risk among HIV and TB patients within the context of the COVID-19 pandemic: The South African response to COVID-19 (17 April 2020) details facility-specific measures to reduce COVID-19 exposure and makes specific recommendations for scaling up multi-month dispensation and use of external pick-up points.

Early in 2020, the health department revised the standard operating procedures for the national Adherence Guidelines for HIV, TB and NCDs, including modifying eligibility for and procedures of repeat prescription collection strategies (RPCSs) for clinically stable clients. It outlines details of facility pick-up points, facility and community adherence clubs, external pick-up points and how to do drug switches for RPCS clients.  

The department launched the updated National Strategic Plan for HIV, TB and STIs 2017-2022 on 31 March 2017. It states that all people living with one or more of the three diseases covered by the National Strategic Plan (NSP) will have access to differentiated service delivery (DSD). A document summarizing the goals and objectives of the updated NSP highlights DSD as a “game-changer”.

The Southern African HIV Clinicians Society published guidelines in 2017 recommending strategies to support adolescents and young adults in achieving and maintaining viral suppression. These are the first in sub-Saharan Africa to recognize the need to differentiate service delivery models for stable or unstable adolescents and young adults either in or after their first year of treatment. In the same year, the society released a supplement guideline on HIV self-testing.

South Sudan

In April 2020, the Ministry of Health in South Sudan issued HIV programme Guidance in the context of COVID-19 Pandemic, which includes recommendations for three to six monthly ART dispensing and maximizing community-based ART distribution.

Tanzania

On 9 April 2020, the Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children published Interim Guidance on Provision of HIV Prevention and Care Services in the Context of COVID-19 Outbreak in Tanzania, which aims to ensure uninterrupted service provision for people living with HIV, while implementing standard precautions against COVID-19.

In 2019, the ministry's National AIDS Control Programme (NACP) launched the National Accelerated Action Plan on HIV Testing Services along with the National Comprehensive Guidelines on HIV Testing Services. The latter recommends a differentiated testing approach, including special considerations for children and adolescents and pregnant and breastfeeding women, as well as key and other vulnerable populations.

In 2017, the ministry and NACP published National Guidelines for the Management of HIV and AIDS (6th Edition).  This comprehensive document includes section 2.4 on ‘Service Delivery Models (SDM) for Differentiated Care’, which utilizes the building blocks approach to design appropriate service delivery models.  Learn more about the building blocks approach here.  In a joint effort, the ministry and the International Training and Education Centre for Health released HIV Service Delivery Models: Mapping HIV Service Delivery Strategies in Tanzania in the same year.

Togo

In March 2020, the Ministry of Health and Public Hygiene in Togo issued an emergency order in the context of the COVID-19 pandemic, allowing for three monthly ART dispensing (3MMD).

Uganda

In Uganda, the Ministry of Health published COVID-19 Infection Prevention and Control Guidance for HIV & TB Services Delivery in April 2020. It includes recommendations to reduce congestion at health facilities and suspension of some community-based services. This document is supported by Frequently Asked Questions by Health Care Providers Regarding HIV and TB Service Delivery During COVID-19 Lockdown (April 2020), which provides practical guidance on HIV and TB service delivery issues.

In late 2016, the ministry published Consolidated guidelines for prevention and treatment of HIV in Uganda, with additional guidance on differentiated service delivery. Section 9.1 is entitled “Differentiated service delivery” and includes a building blocks approach with models for differentiated HIV testing, care and treatment. See also community client-led ART delivery (CCLAD) and community drug distribution points (CDDPs) for more information.  In October 2017, an implementation guide for differentiated delivery of HIV and TB services was launched to support scale up.

Zambia

On 24 March 2020, the Zambian Ministry of Health published a circular, Multi-Month Dispensation and use of TLE/TLD during the COVID-19 pandemic, recommending the promotion of three or six monthly (3MMD or 6MMD) dispensation and temporary replacement of Tenofovir Lamivudine Dolutegravir (TLD) with Tenofovir Lamivudine Efavirenz (TLE) until adequate TLD stocks are available.

The ministry updated its Consolidated Guidelines for Treatment and Prevention of HIV Infection in 2018, expanding on guidelines for differentiated service delivery for clinically stable clients and people living with advanced HIV disease.  

Zimbabwe

The Zimbabwean Ministry of Health and Child Care released Rapid Guidance on HIV Service Delivery in COVID-19 Context on 26 March 2020. It aims to ensure continuity of HIV services while mitigating risk for COVID-19 and includes specific guidance on multi-month antiretroviral therapy dispensation, as well as alterations to prevention services. Its job aide for healthcare workers, COVID-19 and HIV (April 2020), supports the guidance document and suggests telephonic and social messaging for treatment monitoring and psychosocial support.

The ministry updated its Operational and Service Delivery Manual for the Prevention, Care and Treatment of HIV in Zimbabwe in February 2017. It sets out “how” to implement WHO’s 2016 clinical guidelines, including differentiated service delivery, across the entire HIV cascade from testing to suppression. The manual also includes standard operating procedures and outlines the five-step process for deciding how to differentiate service delivery at a district level. To accompany the manual, the ministry also developed the Consolidated HIV and AIDS Job Aide that includes checklists, clinical algorithms and educational tools to support implementation.