Lillian Mworeko, International Community of Women living with HIV Eastern Africa (ICWEA), Uganda, writes: 

Differentiated service delivery (DSD) models should be designed and delivered around the choices, options and priorities of service recipients. Putting the service recipient at the centre means making sure that they meaningfully participate in decision making about what, when, where and how they access services. Furthermore, it means acknowledging that the needs and priorities of people living with HIV change over time and may require transition to a different model.

The changes that may require a service delivery transition can be related to ageing, pregnancy, clinical stability and other personal circumstances.

DSD models that are truly centred around the needs of people living with HIV must not only focus on processes, procedures and protocols, but also pay attention to facilitating effective transitions or moves between models.

Too often, services do not appropriately respond to the heterogeneity of people living with HIV and the dynamic nature of their lifelong antiretroviral therapy (ART) journey.

For example, the needs of a young person who is in secondary school will shift when they start attending university. A pregnant woman’s priorities and needs may change over time. In my country, many pregnant women will travel to their up-country homes, close to their own mothers, to deliver their babies and receive support. Before travelling, the expecting mother may need to get ART refills for a long period, even up to a year, so that if she delays coming back to the city, her treatment will be uninterrupted. These circumstances require a system that is flexible and supportive, provides space for dialogue with clients and invests in feedback mechanisms.  

An adult who used to receive six-month ART refills may find it difficult to maintain this schedule when staying with grandchildren to whom they may never want to disclose their HIV status. Such a person may wish to be moved to a model with monthly medication pick up. Similarly, a person who started a new job and does not want to disclose their HIV status to their employer may struggle to attend their appointment at the facility even if there is need for CD4 or viral load testing.

The examples I have given illustrate that a model that works well for an individual today may not work tomorrow. In such cases, we need the system to listen to the individual and support the person to access the services they need and that work best for them. Such an approach to service delivery will support long-term treatment adherence and retention in care.