We spoke with Dr Kiggundu about Uganda’s experience in implementing DSD for HIV testing and treatment, cost effectiveness and health outcomes, as well as recent service adaptations due to COVID-19.
What do you want people to know about DSD in Uganda?
Uganda adopted DSD in its 2016 edition of the Consolidated guidelines for prevention and treatment of HIV in Uganda 1. Following a national capacity building initiative the next year, implementation of DSD pilots started in 2018.
Uganda endorses DSD for HIV and TB, including HIV testing and treatment.
Our differentiated HIV testing services (HTS) are aimed at closing the identification gap through targeting, integration, decentralization and task shifting. While all communities are eligible for HTS, each HTS model is designed to respond to a specific population’s vulnerabilities and unique needs.
Differentiated care and treatment services are designed to simplify access and increase uptake of HIV care and treatment by responding to the needs and preferences of the recipients of care. All people living with HIV who are in care are eligible for some form of DSD.
What are the main cost drivers in the provision of HIV treatment and care in Uganda?
Antiretrovirals (ARVs) and laboratory tests are the most expensive components of any HIV treatment and care programme – and these costs remain largely the same regardless of the DSD model in which they are provided. Costs of non-ARV medicines and human resources are lower in the less intensive DSD models than the intensive DSD models.
Additional costs are related to capacity building and overheads.
Community-based DSD models for HIV treatment have been widely implemented in Uganda. What can you share regarding the cost effectiveness of these models?
Models like community drug distribution points (CDDPs) and community client-led ART delivery (CCLAD) have proven to be more cost effective than the facility-based DSD models. These models reduce costs for recipients of care as transport costs are reduced.
However, the CDDP model is associated with more costs than other community models because CDDPs are facilitated by healthcare workers. Taking services closer to the homes of recipients of care leads to increased costs for healthcare workers’ transport and allowances.
Which models do clients prefer from both a cost and quality perspective?
We have seen large numbers of recipients of care in the fast-track model, likely because it offers many benefits. With fast-track, there’s less waiting time at the facility, people can receive ARVs for three or six months and they can access healthcare workers as required.
In the context of COVID-19, in April 2020, the MoH Uganda recommended continuing community drug distribution models and moving to three-month dispensing of ARVs for all clients with suppressed viral loads. What are the key lessons learned from these adaptations?
Pilots of CDDPs have shown high retention and viral load suppression rates, but we have not been able to comprehensively evaluate their overall contribution to the HIV programme. CDDPs can address access to treatment issues and provide care closer to home. However, as mentioned, this model does incur costs, with healthcare workers providing services outside of the health facility.
We will continue supporting implementation of community-based models where addressing access to treatment issues outweighs the cost.
1 Updated guidelines were published in early 2020 alongside an implementation guide.