What is DSD?
Differentiated service delivery (DSD), previously referred to as differentiated care, is a client-centred approach that simplifies and adapts HIV services across the cascade to reflect the preferences, expectations and needs of people living with and vulnerable to HIV while reducing unnecessary burdens on the health system.
The World Health Organization has recommended DSD for HIV treatment since 2015. Published evidence from the past decade shows that DSD can:
Enhance client outcomes, including quality of care.
Ensure that the health system functions efficiently.
Enable the health system to refocus resources to those most in need.
What are the core principles of DSD?
The core principle of DSD for HIV is to provide prevention, testing, treatment and care in a way that acknowledges the specific barriers identified by clients and empowers them to manage their disease and/or prevention with the support of the health system. The World Health Organization (WHO) recognizes the need for client-centred care to improve the quality of HIV care services.
Health system efficiency
People living with and vulnerable to HIV have diverse needs that will not be met by a health system that adopts a “one-size-fits-all” approach. DSD enables the shifting of resources to people who are most in need by supporting clients who are established on ART to have fewer interactions with the health system.
Why is DSD important?
1. It improves people’s lives
Most importantly, DSD can improve the quality of care and access to treatment and prevention for people living with HIV. It can better reach underserved populations and address issues surrounding stigma and discrimination, which many people living with and vulnerable to HIV face when accessing HIV services.
2. It improves health system efficiencies and outcomes
Supporting people living with HIV to initiate antiretroviral therapy (ART) is critical, but it is not enough: retention in care and adherence to effective treatments is required to achieve viral suppression. Data from sites where DSD for HIV treatment has been adopted show that such interventions can be part of improving retention and adherence and achieving the second and third “95” in the UNAIDS “95-95-95” global targets.
3. It supports “treat all”
Globally, 38 million people were living with HIV and an estimated 25.4 million people were receiving ART at the end of 2019. With the implementation of the WHO recommendation to “treat all” people living with HIV with ART, health systems, which are often already under extreme pressure due to lack of human and financial resources, have had to re-examine how ART care is delivered.
4. It helps reach 95-95-95
The global target by 2030 is for 95% of people living with HIV to know their status, 95% of people living with HIV to be on ART, and 95% of people on treatment to be virally suppressed – or 95-95-95. There are still considerable gaps to be filled before reaching each of these ambitious targets. In addition, funding for the response has largely stagnated or decreased, adding further pressure to health systems.
The 95-95-95 global target by 2030 is for:
1. 95% of people living with HIV know their status.
2. 95% who know their status are on ART.
3. 95% of those on ART are virologically suppressed.
Differentiated service delivery includes DSD for HIV prevention, for testing and for treatment. Therefore, DSD applies across the HIV continuum to all three of the 95-95-95 targets.
Is DSD just for HIV treatment?
No. Differentiated delivery of HIV treatment is a component of DSD, find out more here:
DSD for HIV treatment focuses specifically on clients who are on treatment, aiming to improve their retention and viral suppression by optimizing models of delivery.
Models of DSD for HIV treatment are divided into four categories:
1. Healthcare worker-managed group models
2. Client-managed group models
3. Facility-based individual models
4. Out-of-facility individual models
In all of these models, clients continue to have clinical consultations as part of their package of care. These models are also flexible to accommodate clients who may want or require up referral to the standard of care. A summary of the published evidence for each of the DSD for HIV treatment models is available here.
Find out more about DSD for HIV treatment here.
DSD for HIV prevention
Does DSD include prevention for key populations?
Yes. Differentiated service delivery includes DSD for HIV prevention and DSD for key populations. There are several examples of successful DSD for key populations. The community response from key population organizations provides some of the earliest examples of DSD. They include:
- Prevention outreach services run by community-based organizations
- Key population initiatives for testing and linking to health services
- Support groups for key populations living with HIV
- Drop-in centres offering services, such as prevention information and commodities, sexually transmitted infection treatment, opioid substitution therapy and referral services
Building on these successes, incorporating the lessons learned from pilot programmes into approaches supported by the ministry of health may support further scale-up of quality DSD.
Find out more about DSD for HIV prevention here.
DSD for HIV testing
Does DSD include HIV testing?
Yes. DSD for HIV testing applies to the first 95 target (95% of people living with HIV know their HIV status) and supports the second 95 by ensuring access to and uptake of ART. The global HIV testing and treatment cascades from 2015 and 2019 suggest an increase in the knowledge of HIV status by people living with HIV from 66% in 2015 to 81% in 2019.
Depending on the context, specific populations may be less likely to face barriers to accessing HIV testing services. The first 95 target will not be reached without defining who does not know their status in a specific context and without building differentiated HIV testing models to reach them. These DSD models for HIV testing need to be inclusive of mobilization, testing and differentiated linkage approaches to ensure access to the necessary antiretroviral therapy and prevention services.
Find out more about DSD for HIV testing here.
How do I get started in DSD?
See our “Getting started” page for information on selecting a DSD model, implementation costs and funding, as well as staffing and resources.
Common DSD abbreviations
|DSD||Differentiated service delivery|
|DART||Differentiated ART delivery models, also known as DSD for HIV treatment|
|CAG||Community adherence group, a client-managed group model|
|CARG||Community ART refills group – same as a CAG, used in Zimbabwe|
|GAAC||Grupos de Apoio à Adesão Comunitária – Portuguese for CAG, used in Mozambique|
|CCLAD||Community client-led ART delivery model – a client-managed group model in Uganda|
|CCMDD||Central Chronic Medicines Dispensing and Distribution, a South African programme for pre-packing of HIV and other chronic medicines. The medicines pre-packed by CCMDD are used in a number of South Africa’s DSD for HIV treatment models.|
|CDDP||Community drug distribution point (CDDP) – an out of facility individual model in Uganda|
|HTS||HIV testing services|