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.

Operational Guidelines for the Implementation of the “Test and Treat” Strategy in Cameroon (2017)

Implementation guidelines for HIV testing, treatment and 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.

Plan de Contingence PNLS Dans le Contexte de L’Epidemie COVID 19 (2020)

Contingency plan of the National HIV Programme in the context of the COVID-19 epidemic, published 25 March 2020.

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.

Plan opérationnel d’offre des services différenciés en République Démocratique du Congo (2018)

The operational plan outlines priorities for implementing differentiated service delivery models
Manuel d'operationnalisation des modeles différenciés et du guichet unique VIH/TB (2018)

This manual is aimed at HIV and tuberculosis service providers at the operational level

Dominican Republic

In 2016, the Ministry of Public Health in the Dominican Republic released a national guide for HIV care, which recommends multi-month dispensing of ART for certain stable client groups, up to a maximum of three months (3MMD). 

Guía Nacional de Atención VIH/Sida (2016)

National guide for HIV and AIDS care (Spanish)

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.

Memorandum (22 April 2020)

Guidance on provision of chronic care during the COVID-19 pandemic
Community commodity distribution concept note (April 2020)

Guidance on HIV related commodity distribution during the COVID-19 pandemic
Standard operating procedures for community centered models of HIV testing and ART service delivery for key populations (2018)

SOPs for community-centered models of HIV testing and ART delivery for key populations in Eswatini
National Policy Guidelines For Community-Centred Models of ART Service Delivery (CommART) in Swaziland (2016)

Guidelines on differentiated ART service delivery in Eswatini

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. Second Edition in May 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.

Interim Guidance for management of People Living with HIV (PLHIV) in the context of COVID-19 Outbreak in Ethiopia. Second Edition. (May 2020)

Guidance on HIV related health services during the COVID-19 pandemic
National guidelines for comprehensive HIV prevention, care and treatment (2017)

This guideline recommends appointment spacing and extended ART refills

Ghana

On 16 March 2020, the Ghana Health Service released Guidance for the Care of Persons Living with HIV (PLHIV) in the Wake of COVID-19, which details various measures to ensure smooth continuation of HIV services, including reinforcement of multi-month scripting (3 or 6 multi-month dispensation).

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.

Guidance for the Care of Persons Living with HIV (PLHIV) in the Wake of COVID-19

Guidance on HIV health service provision during the COVID-19 pandemic
Differentiated service delivery for HIV in Ghana: An Operational Manual (2017)

The manual focuses on the “how” to differentiated HIV care

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”.

Guide de mise en place. Rendez-vous à six mois: Un modèle différencié d’accès au traitement antirétroviral : L’espacement des visites pour les personnes vivant avec le VIH (2019)

Implementation guide for appointment spacing and six-monthly ART refills

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.

In 2017, the Ministry published the National Strategic Plan for HIV/AIDS and STI 2017-2024.  In this document, “Annexure 4.  Differentiated Care Model” details a proposed “2 prong approach” to decentralize and decongest HIV services, which includes multi-month ART dispensing (MMD) and ART distribution via community-led ART refill groups.

Guidance Note for Persons engaged in HIV/AIDS response under National AIDS Control Programme in view of the COVID-19 scenario (March 2020)

Guidance on HIV related health services during the COVID-19 pandemic
National Strategic Plan for HIV/AIDS and STI 2017-2024 (2017)

In this NSP, Annexure 4 highlights proposed DSD models

Kenya

On 24 August 2020, the Ministry of Health released Updated Operational Guidance on Continuity of Health Services in HIV Prevention, Care and Treatment in the Context of the COVID-19 Pandemic. Included in this update is information guidance on multi-month dispensing (MMD) for PrEP, as well as updated guidance on managing MMD of ART.  Earlier COVID-19 guidance from the Ministry recommended promotion of flexible ART delivery models, such as community ART group distribution, among other measures.

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. 

COVID-19 Guidance on Comprehensive HIV Service Delivery (March 2020)

Guidance on HIV service delivery during the COVID-19 pandemic
Guidelines on use of antiretroviral drugs for treating and preventing HIV in Kenya (2018)

A guideline for Kenyan health service providers on HIV prevention and treatment
Differentiated Care: Operational Guidance (2017)

A guide for healthcare workers to plan, implement, and evaluate differentiated care

Lesotho

In 2020, the Ministry of Health in Lesotho released Approach to the Management of Advanced HIV Disease (AHD).  This recommends differentiation of services for stable clients in order to reduce clinical visit frequency and enable health facilities to focus resources on those who require more intensive clinical support.  It includes section 4.5.3 “Differentiated service delivery for AHD clients”.

On 9 July 2020, the Ministry released Coronavirus Disease – 2019 (COVID-19) Screening, Testing, Clinical Management, and Prevention of COVID-19 Guidelines for Clinicians, including a section pertaining to HIV (page 30).  This section details changes to various differentiated service delivery (DSD) initiatives including increased uptake of multi-month ART refills (MMD) for stable clients, multi-month dispensation of TB preventative therapy and supporting telephonic follow-ups among unstable people living with HIV. Further, the guidelines noted that additional community ART delivery models may be introduced by the Ministry.  These guidelines compliment the April 2020 memo HIV program services delivery COVID 19 lock down guidance that advocated for health facilities to promote and facilitate community ART groups.

Coronavirus Disease – 2019 (COVID-19) Screening, Testing, Clinical Management, and Prevention of COVID-19 Guidelines for Clinicians (July 2020)

See page 30 for HIV and DSD
Approach to the Management of Advanced HIV Disease (AHD) (July 2020)

Advanced HIV disease manual that defines the AHD package of care in Lesotho.
HIV program services delivery COVID 19 lock down guidance (April 2020)

Memo on HIV services during COVID-19

Liberia

In September 2020, the Liberian National AIDS and STI Control Program (NACP) updated 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.

National AIDS and STI Control Program SOP for six monthly ART dispensation (Updated September 2020)

SOP for 6MMD with eligibility criteria
Interim Guidance for COVID-19 for all Persons with HIV (March 2020)

Guidance on HIV service delivery during the COVID-19 pandemic

Malawi

On 14 August 2020, the Ministry of Health issued the 4th edition of the circular, Guidance for HIV Services during COVID-19 pandemic, which provides updated guidance on safe resumption of certain HIV services, including resumption of all community HIV services.  Earlier editions of this circular included introduction of six monthly dispensing (6MMD) for certain ART regimens, among other measures.

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

Guidance for HIV Services during COVID-19 pandemic (4th edition) (August 2020)

Updated guidance on HIV service delivery during the COVID-19 pandemic
Guidelines on clinical management of HIV in children and adults for Malawi (2016)

May 2016 ART guidelines for Malawi, including differentiated care appointment spacing and ART refills periods for stable adult and child clients

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.

Pacote de Serviꞔos para Populaꞔões vivendo com o HIV no âmbito da resposta ao COVID-19 (March 2020)

Guidance on HIV service delivery during the COVID-19 pandemic
Guião Orientador sobre Modelos Diferenciados de Serviꞔos em Moꞔambique (2018)

Guidance from the ministry on differentiated service delivery across the HIV care cascade
Estratégia de Grupos de Apoio e Adesão Communitária (2015)

A guide to implementing Community Adherence and Support Groups (CASG) and written in Portuguese 

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.

National guidelines for antiretroviral therapy 6th Edition (2019)

National ART guidelines including a chapter on DSD

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.

National guidelines for HIV prevention treatment and care (2016)

The national HIV guidelines from Nigeria’s Federal Ministry of Health

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.

National Guidelines for Prevention and Management of HIV and STIs (2016)

The policy outlines eligibility criteria for differentiated ART delivery 

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. 

COVID-19 guidance on comprehensive HIV service delivery (May 2020)

Guidance on HIV service delivery during the COVID-19 pandemic
Guide of differentiated care model in Sierra Leone: Who feels it knows it (2018)

Guidance from the Ministry of Health and Sanitation in Sierra Leone on differentiated service delivery

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.

Response to reduce risk among HIV and TB patients within the context of the COVID-19 pandemic: The South African response to COVID-19 (April 2020)

Guidance on HIV and TB service delivery during the COVID-19 pandemic
Guidance to Implementing Partners Regarding Managing Clients on Pre-Exposure Prophylaxis (PrEP) during State of Emergency (sic) COVID-19 (March 2020)

Guidance on PrEP client management during the COVID-19 pandemic
Standard Operating Procedures. Minimum Package of Interventions to Support Linkage to Care, Adherence and Retention in Care (2020)

Revised standard operating procedures for the national Adherence Guidelines for HIV, TB and NCDs
Southern African HIV Clinicians Society Guidelines: Adherence to antiretroviral therapy in adolescents and young adults (2017)

Guidelines recommending strategies to support adolescents and young adults in achieving and maintaining viral suppression
A supplement to the National HIV Testing Services Policy 2016 (2017)

A publication of the Southern African HIV Clinicians Society on HIV self-testing
The South African National Strategic Plan for HIV, TB and STIs 2017 – 2022 (NSP) (2017)

The full version of the NSP with differentiated care highlighted as a core approach to increase access to health services
Let Our Actions Count on HIV, TB & STIs Report (2017)

Reflections on the National Strategic Plan 2012-2016 and moving forward to the National Strategic Plan 2017-2022 with differentiated care a key strategy
Adherence guidelines for HIV, TB and NCDs (2016)

Policy and service delivery guidelines for linkage to care, adherence to treatment and retention in care

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.

HIV programme Guidance in the context of COVID-19 Pandemic (April 2020)

Guidance on HIV programme adjustments during COVID-19

Tanzania

In 2020, the Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children published the updated Interim Guidance on Provision of HIV Prevention and Care Services in the Context of COVID-19 Outbreak in Tanzania - Second Edition, 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.  The same year, the Ministryand NACP published National Guidelines for the Management of HIV and AIDS (7th Edition).  This comprehensive document includes section 2.4 on “Differentiated Service Delivery Models (DSDMs)”, which recommends using the building blocks approach to design appropriate service delivery models that take into account the needs of specific populations.  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 2017.

 

Interim Guidance on Provision of HIV Prevention and Care Services in the Context of COVID-19 Outbreak in Tanzania - Second Edition (2020)

Guidance on HIV service delivery during the COVID-19 pandemic
National Accelerated Action Plan on HIV Testing Services (2019-2020)

This plan includes a mix of HTS strategies, population-specific targets and accentuates on quality, efficiency, yield and linkage
National Comprehensive Guidelines on HIV Testing Services (2019)

These guidelines provide a framework to facilitate access to safe and ethical
testing services for different population groups
National Guidelines for the Management of HIV and AIDS (7th Edition) (2019)

Comprehensive guidelines for HIV service delivery including DSD models
HIV Service Delivery Models: Mapping HIV Service Delivery Strategies in Tanzania (2017)

A report on service delivery models currently being implemented across the HIV prevention, care and treatment cascade

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).

Commande d’urgence des sites MMD (March 2020)

COVID-19 emergency order for 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 early 2020, the ministry published updated Consolidated guidelines for prevention and treatment of HIV in Uganda.  This comprehensive document includes section 10.1 “Differentiated Service Delivery”, which recommends using the building blocks approach to design appropriate service delivery models that take into account the needs of specific populations.  Learn more about the building blocks approach here.  This guideline is supported by Implementation guide for Differentiated Service Delivery Models (DSDM) for HIV and TB services in Uganda (version March 2020).

COVID-19 Infection Prevention and Control Guidance for HIV & TB Services Delivery (April 2020)

Guidance on HIV and TB service delivery during the COVID-19 pandemic
Frequently Asked Questions by Health Care Providers Regarding HIV and TB Service Delivery During COVID-19 Lockdown (April 2020)

FAQs on COVID-19 guidance
Implementation guide for Differentiated Service Delivery Models (DSDM) for HIV and TB services in Uganda (version March 2020)

This guide details how to implement DSD for HIV and TB
Consolidated guidelines for prevention and treatment of HIV in Uganda (2020)

The Consolidated Guidelines include models for differentiated HIV testing, care and treatment

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.  

Multi-Month Dispensation and use of TLE/TLD during the COVID-19 pandemic (March 2020)

Guidance on Tenofovir Lamivudine Efavirenz/Tenofovir Lamivudine Dolutegravir dispensation during the COVID-19 pandemic
Zambia Consolidated Guidelines for Prevention and Treatment of HIV Infection (2018)

Updated Consolidated Guidelines expanding on DSD guidelines for clinically stable clients and for 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.

Rapid Guidance on HIV Service Delivery in COVID-19 Context (March 2020)

Guidance on HIV service delivery during the COVID-19 pandemic
COVID-19 and HIV (April 2020)

COVID-19 and HIV job aide
Operational and service delivery manual for the prevention, care and treatment of HIV in Zimbabwe (2017)

This manual gives guidance on 'how' to implement differentiated service delivery across the HIV cascade
Consolidated HIV and AIDS Job Aide (2017)

The Job Aide includes checklists, clinical algorithms and educational tools to support implementation of differentiated service delivery across the HIV cascade