Prevention

DSD for HIV prevention

According to the recent 2024 UNAIDS report, From Crisis to Opportunity, PrEP (pre-exposure prophylaxis) coverage remains below global targets (see figure below), despite considerable progress. Additionally, access to PrEP varies between different regions, highlighting disparities in availability and implementation.

The emergency response to the COVID-19 pandemic quickly leveraged differentiated service delivery (DSD) approaches that were already being used for treatment. This led to simplified, decentralized, and de-medicalized PrEP service delivery and expanded the scale of PrEP access.

In 2022, the World Health Organization (WHO) launched the technical brief, Differentiated and simplified pre-exposure prophylaxis for HIV prevention: update to WHO implementation guidance, to support the implementation of DSD for PrEP. This guidance summarizes existing evidence and recommendations to enhance the accessibility and effectiveness of PrEP services. It provides the building blocks for adaptation of DSD for PrEP in different contexts and for different population groups (table 3). WHO’s 2024 Consolidated guidelines on differentiated HIV testing services recommend the use of HIV self-testing (HIVST) to deliver PrEP, including for initiation, re-initiation and continuation.

In its 2024 Guidelines for HIV post-exposure prophylaxis (PEP), WHO recommends PEP decentralization with service delivery in community-settings as well as task-sharing, to be employed to dispense, distribute, provide and monitor PEP.

DSD can support equity in access to both PrEP and PEP – and positively impact uptake, persistence and effective use.

DSD for PrEP approach

A DSD for HIV prevention approach to PrEP adapts the building blocks for i) PrEP assessment;
ii) PrEP initiation (and re-initiation); iii) early follow-up (0-3 months); and iv) PrEP continuation with PrEP refills and clinical consultations (>3 months).

Following scientific advances in long-acting prevention commodities, it will be important to assess the role of DSD in this context. One long-acting PrEP option, CAB-LA (cabotegravir long-acting), requires more frequent clinic visits, less decentralization, and less task shifting. DSD with LEN (lenacapavir) would allow for clinic visits and injections every six months. Read more

Latest evidence: DSD for prevention – top picks

Feasibility and Impact of Community Pharmacy and Novel Pick-Up Points for Antiretroviral Therapy Pre-exposure Prophylaxis Initiation and Continuation in Low and Middle-income Countries, Lalla-Edward ST, Venter WDF, Curr HIV/AIDS Rep, Nov 2024

This literature review explores recent developments in community access to PrEP for HIV prevention in low- and middle-income countries. While community pharmacies and novel pick-up points offer promising avenues to expand access, operational complexities and regulatory frameworks present significant challenges. The authors conclude that addressing policy gaps, strengthening pharmacist training, and promoting client-centred approaches are essential for scaling up access to PrEP in low- and middle-income countries.

Preferences for Delivery of HIV Prevention Services Among Healthcare Users in South Africa: A Discrete Choice Experiment, Martin CE et al, AIDS Behav, Oct 2024

Through a discrete choice experiment, this study explored preferences for components of a PrEP service delivery package among clients accessing primary healthcare services. PrEP initiation at a pharmacy or mobile clinic was valued equally to initiating PrEP at a clinic. There was a preference for six-monthly over three-monthly follow-up. Participants preferred collecting PrEP from a pharmacy, through home delivery and from a vending machine and preferred HIV self-testing over healthcare provider testing. The authors conclude that there is a need to expand decentralized and self-led HIV prevention services.

Updated guidelines on HIV post-exposure prophylaxis: continued efforts towards increased accessibility, Allan-Blitz LT, Mayer KH, J Int AIDS Soc, 2024 Nov

PEP remains an underutilized HIV prevention tool. This commentary highlights the importance of the 2024 WHO PEP guidelines for increasing access to PEP. The guidelines strongly recommend that: (1) PEP be delivered in community settings (for example, pharmacies, police stations and online platforms); and (2) PEP delivery and monitoring be done via task sharing involving non-specialist health workers. To support implementation, the authors recommend training of the workforce and the development of detailed templates addressing heterogeneity of community settings and of the populations among whom PEP may be needed.

Differentiated Service Delivery Models for Maintaining HIV Treatment and Prevention Services During Crisis and Disease Outbreaks: Lessons from the COVID-19 Pandemic, Njuguna N et al, Curr HIV/AIDS Rep, Oct 2024

To address health system disruptions during the COVID-19 pandemic, countries adopted and scaled DSD models. Successful models employed task shifting, community-based delivery, multi-month scripting and dispensing, and telehealth for remote consultations. This review summarizes DSD models for HIV treatment and prevention that have been adapted for maintaining continuity of services. It proposes strategies for sustaining the benefits of the models now and during future health system disruptions.

Harnessing private sector strategies for family planning to deliver the Dual Prevention Pill, the first multipurpose prevention technology with pre-exposure prophylaxis, in an expanding HIV prevention landscape, Verde Hashim C et al, J Int AIDS Soc, August 2024

This qualitative study, conducted in Kenya, South Africa and Zimbabwe, explored private sector service delivery approaches for the introduction of the dual prevention pill (DPP), which combines oral PrEP with oral contraception. While noting country-specific differences, the authors found that private sector landscapes are well-suited for the introduction of the DPP, particularly via pharmacies, networked private providers and newer, technology-based channels, such as e-pharmacies and telemedicine.

Exploring adolescent girls and young women’s PrEP-user profiles: qualitative insights into differentiated PrEP delivery platform selection and engagement in Cape Town, South Africa, Rousseau E et al, J Int AIDS Soc, May 2024

The Prevention Options for Women Evaluation Research (POWER) study in Cape Town, South Africa, provided PrEP to adolescent girls and young women from four DSD platforms: mobile clinic, government facility, courier delivery, and community-based youth club. This qualitative POWER implementation study explored PrEP-user preferences, decision making, influences and habits related to PrEP. Mobile clinics were the most used PrEP delivery platform, described as acceptable and convenient. The second most popular platform was courier delivery, selected for its privacy, convenience and limited interaction needed.

Effect of differentiated direct-to-pharmacy PrEP refill visits supported with client HIV self-testing on clinic visit time and early PrEP continuation, Zewdie KB et al, J Int AIDS Soc, March 2024

This study evaluated differentiated direct-to-pharmacy PrEP refill visits. Two public health HIV clinics implemented the intervention package, which also included client HIV self-testing, client navigator, and pharmacist-led rapid risk assessment and dispensing; two other clinics served as controls. In the intervention arm, the total time spent at the clinic was reduced by 35% and PrEP continuation was higher.

Differentiated PrEP service delivery: Country policy development brief

Differentiated pre-exposure prophylaxis (PrEP) service delivery. Key considerations in developing policy guidance for differentiated PrEP service delivery (IAS) (2022)

This brief is intended to support countries to develop and include differentiated PrEP service delivery in their national HIV operational guidance.

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