1. Utilizing Implementation Science to build Strategies for Differentiated Service Delivery for HIV
Ruanne V Barnabas,1 MBChB, DPhil, and Heidi van Rooyen2, PhD
1University of Washington and 2Human Sciences Research Council

2. Conflicts of Interest
No conflicts of interest to declare

3. Outline Background Differentiated Service Delivery
Implementation Science based DSD
Addressing efficiency Health economic analyses
Discussion

4. Progress: Reaching 90-90-90 targets
Can Differentiated Service Delivery (DSD) close the treatment and prevention gaps?
UNAIDS 2017

5. Continuum of Care
At each stage in the continuum of care, we need high coverage and uptake to achieve the targets
Wafaa El Sadr, IAS Plenary 2017

6. Challenges along the Care Continuum
Barriers along the HIV care continuum include:
Testing not reaching HIV+ persons esp. key and priority populations
Logistics for linkage to clinic
Limited slots and capacity for ART initiation, monitoring and refills at clinic
Challenges with retention over time
DSD hypothesized to address these challenges
Implementation Science – evaluates DSD strategies

7. Differentiated Service Delivery (DSD)
Client centered approach - simplifies and adapts HIV services from testing  ART initiation  achieving and maintaining viral suppression
Meets expectations of HIV+ people
Reduces burden on the health system  increase efficiency

8. Implementation Science – Identifies effective DSD strategies
Three types of effective DSD strategies
Decentralize services
Streamline and integrate services
Health economics insights

9. Decentralized HIV testing – successful DSD
At population level, client-centered community HTC:
Achieved higher coverage than facility HTC, with home (70%) and campaign (76%) having the highest population coverage compared to 15% and 18%
Sharma et. al. Systematic review and meta-analysis of HIV testing to address linkage to care gaps in sub-Saharan Africa. 2015

10. 1) Decentralized testing
Community based HTC – closer to closing the testing gap
Mobile testing - highest coverage among men (50%)^
Self-testing - highest proportion of young persons (66%)
HIV testing for priority populations (CSW and MSM) - high HIV positivity (38%) and the highest proportion of first-time testers (78%)
Hybrid, mobile HTC of multiple-disease community health campaigns – 89% coverage*
Need additional strategies to identify HIV+ persons who do not know their status
^Sharma et. al., Nature. 2015
*Chamie, et. al., Lancet HIV, 2016

11. Continuum of Care Testing Decentralized testing Integrated screening
-- Reach priority population
Adapted from Wafaa El Sadr, IAS Plenary 2017

12. 2) Streamline ART Initiation
WHO guidelines for ART at all CD4 counts supports rapid ART initiation
Rapid ART initiation following testing increases ART uptake by 36% and viral suppression by 25% 1
Still need pre-ART care for OIs and persons waiting to start
1Rosen S, Fox M, Rohr J, RapIT Study, PLoS Med, 2016

13. Algorithm for rapid ART initiation
Rosen S, PLoS Med, 2016

14. Interventions to improve ART initiation
ART initiation increased with:
Interventions with home HTC (RR=2.00)*
POC CD4 (RR=1.3)
Improved clinic operations (RR=1.36)
Package of patient services (1.54)
*MacPherson, JAMA, 2014
Fox M, et. al. Interventions to improve rate or timing of ART initiation, Meta-analysis, JIAS, 2016

15. Continuum of Care ART Initiation Rapid ART Initiation Community HTC+
Package services
Improved clinic operations
-- Streamlined protocol for rapid ART
Testing
Decentralized testing
Integrated screening
-- Reach priority populations
Wafaa El Sadr, IAS Plenary 2017

16. DSD strategies to improve retention
Community support groups
Uganda & Kenya – home delivery of ART by CHWs or volunteers
Mozambique – self-formed community-based ART groups
South Africa – ART clubs
OR=1.39
Text message interventions to promote ART adherence
Increased adherence with SMS (OR=1.39)
Improved with two-way, less frequently than daily, included personalized message content & matched participant ART schedule
Improved VL and/or CD4 outcome (OR=1.56)
Wilkinson, et. al, J Trop Med Int Health, 2016, Grimsrud, et. al., JAIDS, 2016, Decroo T, Rasschaert F, Telfer B, et. al. Community ART programs review, Int Health, 2013, Finitsis D, Pellowski J, Johnson B, et. al. SMS interventions meta-analysis, PLoS One, 2014

17. DSD strategies to improve retention
Pragmatic trial on South African CACs – low retention at 24 months (53%) (Hanrahan, C, MOAD0106LB)
Family AC – 36 months >85% VS (Wilkinson, L, TUPED1325)
SPEEDI – Visit spacing and fast track ART for pediatric HIV in Tanzania – increased survival (HR 1.78 ( )) (Bacha, J, TUPED1321)

18. Integrate services
Integration of methadone treatment and ART among PWID in Tanzania – 81% VS at 12 months (Lambdin, B. MOAD0206)

19. Viremia increases post-partum
Myer et. al. Frequency of Viremic Episodes in HIV-Infected Women Initiating Antiretroviral Therapy During Pregnancy: A Cohort Study
Clin Infect Dis. 2017;64(4): doi: /cid/ciw792
Distribution of viral load (VL) test results during select intervals of time during pregnancy and postpartum; each column shows results for all tests conducted in the cohort during that interval.

20. Integration of HIV and MCH services increases VS
Intervention arm: Integrated MCH and ART until the end of breastfeeding (referred at median 9 months)
SOC: Referred to ART clinic postpartum (median 9 days)
Integration improves VS and retention in care
Intervention
Control
Absolute Risk Difference
Intervention – Control (95% CI)
p-value
Primary outcome (n=412)
Retained in care AND VL<50 copies/mL at 12m postpartum
155 (77)
117 (56)
21% (12-30%)
<0.001
Myer, et. al. CROI, 2017

21. Continuum of Care ART Initiation Rapid ART Initiation Retention and VS
Community HTC
Package services
Improved clinic operations
-- Streamlined protocol for rapid ART
Retention and VS
Peer support groups
Adherence clubs
Two way SMS
-- Priority populations
-- Integrated services
Testing
Decentralized testing
Integrated screening
-- Reach priority popultions
Wafaa El Sadr, IAS Plenary 2017

22. 3) Integrate health economics: DSD for HIV in Zimbabwe
Phillips, A, et. al. Nature, 2016

23. The DO ART Study: Design
Compare community-based ART delivery to standard clinic-based care in South Africa and Uganda
Randomize 1,800 HIV+ ART-eligible persons to 1 of 3 study arms:
Co-primary endpoints:
Viral suppression at 12 months (>80% to see effect)
Cost per HIV+ person achieving VS
Qualitative assessment of what works and why
Results: Q2 2019

24. DO ART Study: Qualitative Results
Favorable response to community-based care experiences:
Convenience: Saves time and money
Personalized services: one-on-one interactions with CHW allow time to address individual questions
Increased privacy: eliminates the possibility of being recognized at clinics
Responsiveness: focused attention and flexible approaches communicate caring
Acceptable approach that reduces access barriers
Wyatt, M, Ware, N et. al. TUPED1324 IAS, 2017

25. Discussion Client-centeredness is at the heart of DSD
Evidence supports testing 3 DSD features:
Decentralized services
Streamlined and integrated services
Insights from health economics
Implementation science approaches - evaluate impact and cost of DSD
Ongoing evaluation will strengthen DSD

26. Thank you
Study Participants Wafaa El-Sadr, Margaret McNairy, Matthew Fox, Sydney Rosen, Landon Myer, Ingrid Basset, Chris Gordon HSRC, ICOBI, Harvard, AHRI, and UW Partners Heidi van Rooyen, Stephen Asiimwe, Jared Baeten, Jennifer Smith, Adam Szpiro, Norma Ware, Meighan Krows, Torin Schaafsma, Paul Drain, Alastair van Heerden, Monique Wyatt, Bosco Turyamureeba, Elioda Tumwesigye, Monisha Sharma, Allen Roberts, Anna Bershteyn, and Connie Celum
Funding: AI092552, #OPP