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Adoption of differentiated HIV service delivery in Tanzania: from policy to practice

Title
Adoption of differentiated HIV service delivery in Tanzania: from policy to practice
Presenter
Fernanda Freistadt
Authors
F. Freistadt * (1), K. Wilson (1), B. Nyakuya (2), A. Nnko (2), G. Boyle (1), N. Gabriel (2), A. Makoi (3), E. Matiko (3), A. Ramadhani (4), A. Rwebembera (4), M. Rutaihwa (4), H. Bygrave (5), S. Chale (2), P. Kohler (6).
Institutions
(1) University of Washington - International and Education Center for Health (I-TECH), Department of Global Health, Seattle, United States, (2) International Training and Education Center for Health (I-TECH) Tanzania, Dar es Salaam, Tanzania, United Republic of, (3) US Centers for Disease Control and Prevention, Division of HIV and TB, Dar es Salaam, Tanzania, United Republic of, (4) Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), Dar es Salaam, Tanzania, United Republic of, (5) International AIDS Society (IAS), Geneva, Switzerland, (6) University of Washington, Department of Child, Family and Population Health Nursing, Seattle, United States

BACKGROUND: Tanzania has scaled up differentiated HIV service delivery models (DSDMs) to ensure patient-centered care and mediate challenges arising from increasing client volume. We describe implementation findings of DSDM adoption by health facilities, assessed during a technical assistance (TA) program in Tanzania.
METHODS: Facility managers from 60 health facilities across 10 regions of Tanzania participated in cross-sectional surveys during TA visits in June and September 2019. TA consisted of guidelines and tools development, training, regional action planning, and facility-based mentoring. Implementation outcomes included dissemination of job tools and adoption of DSDMs for testing and treatment, including facility-based, population-focused, and community-based services at participating facilities. Data were summarized using counts and proportions, medians and interquartile ranges. Outcomes at first visit were compared to follow-up outcomes using chi-square tests.
RESULTS: Facilities included 10 regional/zonal hospitals (17%), 15 district hospitals (25%), 12 dispensaries (20%), and 23 health centers (38%); the majority in urban settings (n=37, 62%). All managers reported adoption of at least one differentiated testing and ART delivery at their facility. There was an increase in uptake of testing models for key and vulnerable populations (54% at baseline to 70% at follow-up, p=0.06) and implementation of adolescent testing models (85% to 92%, p=0.25). Adoption of facility-based index testing was 100% at both timepoints, and community index testing remained low (10% both timepoints). A significant increase in adoption of treatment DSDMs was observed for mobile populations (17% to 35%, p=0.02). Adoption of multi-month refill models (100% both timepoints), extended hours for ART refills (87% to 88%) and fast-track refill (82% to 88%) remained high. Community refills by healthcare workers (29% to 35%), and facility-based group refills (9% to 18%) improved but remained low, family refills decreased (49% to 42%). Nearly all facilities had national HIV guidelines (92% to 95%), and operational manual and job aids (58% to 98% for both) available.
CONCLUSIONS: As differentiated care scales throughout Tanzania, there is variation in uptake of DSDMs. Population-focused and pharmacy-based models were more readily adopted by health facilities, while challenges persisted, even after technical support, with models requiring community or group delivery.