Photo credit: MSF/Sven Torfinn

Reflections on IAS 2021: DSD in times of COVID-19

 By Mwanza Wa Mwanza, Director Clinical Care Services, Center for Infectious Disease Research in Zambia (CIDRZ), Zambia

At IAS 2021 – the 11th IAS Conference on HIV Science – held virtually on 18-21 July, a large number of abstracts and presentations demonstrated the resilience of HIV programmes, communities and people living with HIV in mitigating the effects of the COVID-19 pandemic on health systems. Throughout the conference, my main focus was to learn more about the adaptations of differentiated service delivery (DSD) for HIV treatment during COVID-19, including expanding eligibility criteria, extending multi-month dispensation (MMD) of antiretroviral therapy (ART) and scaling up community-based models.

In South Africa, a rapid rebound in HIV service utilization among key populations was observed in the weeks following initial service interruptions. This was thanks to service delivery innovations, including increased mobile testing, ART home delivery and increased peer navigation. In Kenya, longer appointment spacing significantly increased during the COVID-19 period, enabling continuity of HIV service delivery. DSD model adaptations implemented by FHI 360 in five Kenyan counties led to improvements in viral load testing coverage and suppression rates despite challenges posed by COVID-19.

In the Democratic Republic of the Congo, COVID-19 adaptations to the community-based DSD model (PODI+) included integration of appointment reminders, monthly virtual adherence and health checks between appointments, and shifting eligible clients from three- to six-month ART dispensing, leading to higher viral suppression and retention rates.

Across sub-Saharan Africa, countries made MMD of ART available for children, as shown in this PEPFAR programme data analysis. By the end of September 2020, nearly half (45.9%) of children 15 years and younger living with HIV across 12 PEPFAR countries were receiving 3-5 MMD, a significant increase from 32.0% 3-5 MMD coverage at the beginning of 2020. This analysis of routine data from Zambia, where MMD was scaled up to younger age groups as a response to COVID-19, showed that providing a minimum three-month dispensing of ART to children from the age of two years had no adverse impact on their viral load coverage or suppression and decreased disengagement rates. A rapid scale up of providing people aged 15 years and older in Zambia with six-month ART refills led to an improvement in retention rates.

A key take-home message from the conference for those implementing services in high HIV-burden countries (like Zambia, where access and uptake of COVID-19 vaccination are still very low) is to leverage DSD adaptions to integrate COVID-19 vaccinations and thereby increase vaccination uptake among people living with HIV. To further improve the quality of service delivery, as recommended by the new World Health Organization guidelines presented at this satellite session, Zambia should consider permanently expanding DSD eligibility criteria, reducing the frequency of clinic visits, expanding MMD up to six months and promoting community ART distribution models.