Are you an ART programme manager, facility manager or healthcare worker looking to adopt DSD but not sure where to begin? This section aims to provide the information you need to get started.
What is DSD? │ Why is DSD important?
The DSD cascade
Since 2015, the majority of implementation and evidence in DSD has focused on DSD for HIV treatment in high HIV-prevalence settings with adult clients who are established on ART. However, DSD has emerged as an approach for HIV programmes across:
The cascade – HIV prevention, testing, treatment and integration.
Populations, including key populations, men, pregnant and breastfeeding women, adolescents and children.
Contexts of high and low HIV burden.
DSD across the cascade
Click here for more information on implementing DSD for HIV prevention
Click here for more information on implementing DSD for HIV testing
Click here for more information on implementing DSD for HIV treatment
What are the three elements
DSD should be implemented as a response to specific challenges or barriers and where differentiation may serve to improve quality of care, outcomes and health systems efficiencies.
In determining the appropriate DSD models, it is critical to consider the three elements.
Based on clinical characteristics, clients can be defined as: established on ART (previously termed “stable”); not yet established on ART (previously termed “unstable”); and clients with co-morbidities or co-infections. A client can be determined as established on ART according to WHO’s definition or another definition. Clients not yet established on ART may have a high viral load or another characteristic, such as a mental health condition or being recently initiated on ART, that classifies them as not yet established on ART.
The delivery of HIV treatment should be differentiated based not only on clinical characteristics, but also by considering the needs and preferences of specific populations.
Although this compendium website currently focuses on clients who are established on ART (previously termed “stable clients”), the same concepts and principles from the building blocks can be applied to provide appropriate models of DSD for HIV treatment for specific populations. Differentiating HIV treatment for specific populations can help improve access to HIV care by addressing the structural barriers and adherence issues that specific populations often face.
Each specific population will require a unique and comprehensive package of health care services to best respond to their needs and preferences.
In order to maintain quality HIV treatment delivery in specific contexts, modifications to how HIV treatment is delivered are required. In addition to the consideration of contextual stability, the prevalence of HIV in a given setting will also impact on the specific challenges faced by clients and the appropriateness or extent of specific interventions.
DSD building blocks
What are the building blocks of DSD?
The building blocks are the foundation of any DSD model. Each building block poses a key question to help form the building blocks of your service:
1. WHEN – how often are services provided?
2. WHERE – in what location are services provided?
3. WHO – who is providing the services?
4. WHAT – what does the package of services include?
Implementation costs and funding
What will it cost?
Costing data is increasingly available across a range of differentiated ART delivery models, with a number of costing studies in process or completed in 2020. These are well summarized in this CQUIN webinar. The largest cost contributors to any ART delivery model remain drugs and laboratory investigations. While DSD models may provide some provider (health system) savings, these are unlikely to be significant. Importantly, there are substantial cost saving from the client perspective, as reported in this systematic review. In addition, the costing component of a 2020 Lesotho cluster-randomized trial showed client savings of 60%.
Further costing studies for DSD for HIV treatment models are detailed in our evidence summaries here.
Do donors accept and support DSD?
Yes. The Global Fund strongly encourages countries to include DSD scale-up implementation plans in its funding requests in its September 2019 Information Note, which specifies community ART dispensing. The United States President’s Emergency Plan for AIDS Relief (PEPFAR) requires and provides technical guidance on DSD implementation in its 2020 Country Operational Plan Guidance for all PEPFAR countries. In these guidelines, PEPFAR specifically requires multi-month dispensing (MMD) for 80% of clients who are established on ART, with a compulsory Monitoring, Evaluation, and Reporting (MER) indicator to track implementation.
Do we need additional staff for DSD?
This depends on the DSD model being implemented. Facility-based models usually don’t require additional staff. However, as client numbers increase at facilities, increasing the number of lay providers to take on DSD management may prove to be more cost efficient than appointing more professional cadre staff. Healthcare worker-managed or supported community models may require additional lay provider staff or, at a minimum, a re-organization of existing community-based staff tasks to support DSD management. Some health ministries are increasingly engaging (and paying for) private service providers to take on community-based DSD service delivery, such as community pharmacies.
Can lay providers facilitate DSD?
Lay providers have been key to the success of many of the models of DSD for HIV treatment. For example, lay providers have distributed pre-packed ART at community pick-up points, facilitated ART adherence clubs, and supported the formation of community ART groups.
While volunteer lay providers have been utilized and can be highly effective when well coordinated, relying solely on voluntary services is not recommended for creating a long-term, sustainable and consistent provision of DSD. Lay providers are essential service providers in DSD models and require appointment and remuneration for their services.
Staff training resources