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Barriers and facilitators to the implementation and scale up of differentiated service delivery models for HIV treatment in Africa: a scoping review

BMC Health Services Research volume 22, Article number: 1431 (2022) Cite this article

Abstract

Background

In the face of health-system constraints, local policymakers and decision-makers face difficult choices about how to implement, expand and institutionalize antiretroviral therapy (ART) services. This scoping review aimed to describe the barriers and facilitators to the implementation and scale up of differentiated service delivery (DSD) models for HIV treatment in Africa.

Methods

PubMed, Web of Science, Embase, Scopus, CINAHL, Global Health, Google, and Google Scholar databases were searched. There was no start date thereby all references up until May 12, 2021, were included in this review. We included studies reported in the English language focusing on stable adult people living with human immune deficiency virus (HIV) on ART and the healthcare providers in Africa. Studies related to children, adolescents, pregnant and lactating women, and key populations (people who inject drugs, men having sex with men, transgender persons, sex workers, and prisoners), and studies about effectiveness, cost, cost-effectiveness, and pre or post-exposure prophylaxis were excluded. A descriptive analysis was done.

Results

Fifty-seven articles fulfilled our eligibility criteria. Several factors influencing DSD implementation and scale-up emerged. There is variability in the reported factors across DSD models and studies, with the same element serving as a facilitator in one context but a barrier in another. Perceived reduction in costs of visit for patients, reduction in staff workload and overburdening of health facilities, and improved or maintained patients’ adherence and retention were reported facilitators for implementing DSD models. Patients’ fear of stigma and discrimination, patients’ and providers’ low literacy levels on the DSD model, ARV drug stock-outs, and supply chain inconsistencies were major barriers affecting DSD model implementation. Stigma, lack of model adoption from providers, and a lack of resources were reported as a bottleneck for the DSD model scale up. Leadership and governance were reported as both a facilitator and a barrier to scaling up the DSD model.

Conclusions

This review has important implications for policy, practice, and research as it increases understanding of the factors that influence DSD model implementation and scale up. Large-scale studies based on implementation and scale up theories, models, and frameworks focusing on each DSD model in each healthcare setting are needed.

Peer Review reports

Background

Africa bears the highest global human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) burden, with over two-thirds of all HIV-positive people (25.7 million) residing in this developing region with severe gaps in access to HIV services (prevention, diagnosis, treatment, and care) [1]. The Joint United Nations Programme on HIV/AIDS (UNAIDS) set 90–90–90 goals for 2020 in response to the HIV epidemic, aiming to ensure that 90% of all individuals living with HIV know their HIV status, 90% of all persons with confirmed HIV infection receive sustained ART, and 90% of all people getting ART have viral suppression. A new 95-95-95 target has been set for 2030 [2]. To achieve the 90-90-90 goals, the World Health Organization (WHO) released ART guidelines recommending a “treat-all” approach, whereby all HIV-positive populations and age groups are eligible for ART [3].

In 2015, the WHO recommended differentiated models of care, emphasizing the need to strengthen the continuum of HIV care and improve service quality and access, adherence and retention, clinical outcomes, efficiency, and cost of services, particularly in high-prevalence countries [3, 4]. The differentiated HIV treatment for clinically stable patients is a component of DSD models for HIV which focus on the second and third 90-90-90 targets [5].

Differentiated HIV treatment models aim to put people at the center of antiretroviral delivery and are characterized by four components: i) types of services delivered; (ii) location of service delivery; (iii) provider of health services; and (iv) frequency of health services [4, 5].

The DSD models for HIV treatment can be described within four categories. In healthcare worker-managed groups, clients receive their ART refills in a group and either a professional or a lay healthcare staff member manages this group. The groups meet within and/or outside of healthcare facilities. In client-managed group models, clients receive their ART refills in a group in which clients meet outside of health care facilities and manage and run the refills themselves. In facility-based individual models, ART refill visits are separated from clinical consultations. When clients have an ART refill visit, they bypass any clinical staff or adherence support and proceed directly to receive their medication. For out-of-facility individual models, ART refills and, in some cases, clinical consultations are provided to individuals outside of healthcare facilities, for example, community pharmacies, outreach models, and home delivery [6].

To achieve the promise of DSD, model adoption, implementation, scale-up, and evaluation are necessary processes [7]. Since 2016, numerous countries, particularly in sub-Saharan Africa and for adults established on ART, have embraced and scaled up DSD as part of national policy [8]. The optimal mix of DSD models for HIV treatment at the national level is specific to each country’s context [9]. The effective implementation and scale-up of DSD models is an ongoing challenge in Africa. The term implementation in relation to health interventions is defined as “the use of strategies to adopt and integrate evidence based health interventions and change practice patterns within specific settings” [10]. The WHO/ ExpandNet defines scale up as: “deliberate efforts to increase the impact of successfully tested health innovations to benefit more people and to foster policy and program development on a lasting basis” [11].

Understanding factors that influence the implementation and scale up of DSD models is a considerable research and practice benefit to get the picture of why DSD model implementation and scale up can succeed or fail. Several studies assessing the barriers and facilitators for DSD implementation and scale up have been conducted in Africa although a little attempt has been made previously to map the available research findings using a scoping review format. Previous literature reviews lacked particular focus and in-depth investigation of the factors influencing the DSD interventions implementation and scale up [12,13,14,15,16]. Therefore, this study aimed to review the available research reporting on barriers and facilitators for the effective implementation and scale-up of DSD models in Africa, to guide policymakers, program managers, and practitioners as they implement, expand and institutionalize ART services.

Methods

This scoping review follows the Joanna Briggs Institute (JBI) methodology for scoping review [17]. We didn’t register the protocol for this study since scoping reviews are currently ineligible for registration in the PROSPERO database. However, we strictly followed the PRISMA ScR checklist [18] to check our scoping review conforms to this reporting standard.

Eligibility criteria

Population

This review is comprised of evidence involving stable adult people living with HIV taking antiretrovirals (ARVs), and the healthcare workers providing ART services. Stable adult HIV-positive clients with a controlled chronic disease were also included. However, the evidence related to children, adolescents, pregnant and lactating women, and key populations (people who inject drugs, men having sex with men, transgender persons, sex workers, and prisoners) were excluded due to special criteria for defining clinically stable clients, and key considerations for social and legal issues in accessing ART services.

Concept

Studies that reported the barriers and facilitators to the implementation and scale-up of DSD models were included.

Context

This review included only studies conducted in Africa, where there is a high burden of HIV and limited public health resources, with a varied range of communities and cultures.

Types of the sources of evidence

The source of information is comprised of studies published in peer-reviewed journals (primary research studies, systematic reviews, and non-systematic reviews), conference proceedings, and unpublished theses and dissertations. Only the English language-based studies were included because of limited resources for the translation of studies conducted in languages other than English. There was no start date thereby all studies up until May 12, 2021, were included in this review. In addition, studies reporting effectiveness, cost, cost-effectiveness, and pre or post-exposure prophylaxis were excluded since these types of studies didn’t directly evaluate the barriers and facilitators affecting the implementation and scale up of specific DSD models.

Search strategy

A three-phase search strategy was carried out using databases including PubMed, Web of Science Core Collection, Embase, Scopus, CINAHL, and Global Health. The first phase was an initial limited search of PubMed to identify relevant records.

Secondly, the search strategy was developed according to the previous phase using all identified keywords and index terms, and it was customized for each included information source. A comprehensive search strategy and set of search terms is contained in Additional file 1. Search terms included

  1. 1.

    patient* OR client* OR provider*

  2. 2.

    “human immunodeficiency virus” OR “human immunodeficiency virus infection” OR HIV OR “antiretroviral treatment” OR “antiretroviral therapy” OR “antiretroviral therapy, highly active” OR “highly active antiretroviral therapy” OR HAART OR ART

  3. 3.

    “patient-centred care” OR “patient-centered care” OR “community supported models” OR “adherence club*” OR “task shifting” OR “community ART distribution” OR “community ART delivery” OR “community ART refill” OR “community client lead ART-delivery” OR “facility fast track” OR “quick pick-up” OR “differentiated care” OR “differentiated service” OR “differentiated intervention” OR “decentrali?ed. care” OR “decentrali?ed. service” OR “decentrali?ed. intervention” OR “community care” OR “community service” OR “community intervention” OR “differentiated model*” OR down-referr* OR out-of-clinic

  4. 4.

    experience* OR attitude* OR perception* OR learning OR Barrie* OR challeng* OR facilitator* OR enabler* OR benefit* OR success* OR constrain* OR difficult* OR enhanc* OR influen* OR interfer* OR motivat* OR obstruct* OR problem* OR promot* OR restrain* OR restrict* OR implement* OR uptake OR adopt* OR adapt* OR accept* OR react* OR appropr* OR feasib* OR fidelity OR sustain* OR modification OR scale-up OR scaling-up OR scale up OR scale-out OR expan* OR replica* OR exten* OR institutionali?ation OR maintain OR continue*

  5. 5.

    Combining all 54 countries in Africa by the Boolean operator ‘OR’

Finally, the reference lists of all the included studies were screened for additional records. Grey literature was also searched from relevant HIV related conference databases (International AIDS Society (IAS), Conference on Retroviruses and Opportunistic Infections (CROI), South African AIDS Conference (SAAIDS), Southern African HIV Clinicians Society (SAHIVSOC), European AIDS Conference (EACS), INTEREST Conference, Zambia Health Research Conference (ZHRC), Asia Pacific AIDS & Co-infections Conference (APACC), and International Conference on AIDS and STI’s in Africa (ICASA)) via Google and Google scholar search engines.

Study selection

All retrieved studies were exported to Endnote version 9 (Thomson Reuters, London) reference manager, and duplications were carefully removed. Two investigators (YAB and FAT) independently screened the titles and abstracts of studies identified from each database using the inclusion and exclusion criteria. Any disagreements that arose between the reviewers were resolved through discussion and the involvement of the third reviewer (MY). Then, full texts were retrieved for all studies that passed the title and abstract screening.

Our search of databases and other sources yielded 4254 records. After removing 2093 duplicate records, 2161 records were screened at the title and abstract level, resulting in 103 records being evaluated for eligibility. From these, 46 records were excluded (38 reported effectiveness of DSD models, 4 reported cost of DSD models, 1 conducted with pregnant and postpartum women, 1 conducted with the pediatric population, 1 conducted with pre-exposure prophylaxis, and 1 focused with DSD 2.0). Ultimately, 57 articles were included in the scoping review (Fig. 1).

Fig. 1
figure 1

PRISMA flow diagram of the included studies

Full size image

Data extraction

The data from full texts of included studies were extracted using a JBI data extraction template in the form of customized Microsoft Excel [17]. Two independent reviewers (YAB and MY) extracted the data and cross-checked it to ensure consistency. Any discrepancies that arose between the reviewers were solved by a discussion with a third reviewer (AA). The reviewer (YAB) contacted the corresponding author(s) for further information whenever pertinent data was missed from the included studies. According to the JBI Reviewers manual [19], descriptive data on the author(s), year, types of evidence source, publication type, country of origin, aims, study design, study population, concept, context, and key findings, in line with the review questions, were extracted (Additional file 2).

Analysis and presentation of results

A descriptive analysis was done in this scoping review. Barriers and facilitators reported in included studies were summarised. The identified barriers and facilitators in this study were clustered according to implementation and scale up aspects of different DSD interventions.

Implementation related barriers and facilitators were further clustered according to the four categories of DSD models for HIV treatment described in practice and the literature: group models managed by healthcare workers; group models managed by clients; individual models based at facilities; and individual models based out of facilities [5]. We have analyzed factors identified from the perspectives of patients and providers and presented these separately in each DSD model category. The scale up related barriers and facilitators were further categorized based on the components of the Health System Dynamics Framework [20].

The search results were presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) Flow Diagram for the scoping review process [21], tables listing the results, and a descriptive summary using texts per the review questions.

Results

Characteristics of included studies

Of all included studies, more than one-third (21) of studies were conducted in South Africa only [12, 22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41], and five of them were undertaken in sub-Saharan Africa [13,14,15,16, 42]. Nearly two-thirds (33) of the included studies were primary published articles [22, 23, 25, 27, 30, 32,33,34,35,36,37,38,39, 43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60] followed by nearly one-fifth (12) of conference abstracts [29, 31, 41, 55, 61,62,63,64,65,66,67,68,69]. The studies included in the scoping review were multi-methods comprising mixed method, qualitative and quantitative types of studies. Nineteen (33.3%) of the studies were descriptive qualitative [22, 24, 28, 29, 32, 33, 39, 47, 49, 52,53,54,55,56, 58,59,60, 62, 68] (Table 1).

Table 1 Summary characteristics of studies included in the scoping review
Full size table

Barriers and facilitators to the implementation of DSD models

Forty-two studies have reported findings on the implementation-related barriers and facilitators. The majority of the included studies highlighted both barriers and facilitators in the same study. Some studies however focused solely on the barriers. Across many DSD models, there were common facilitators and barriers. In addition, there is variability in the reported factors across DSD models and studies, with the same element serving as a facilitator in one context but a barrier in another. The following section summarized the influencing factors according to the four categories of DSD models for HIV treatment (Table 2).

Table 2 Barriers and facilitators to the implementation of differentiated antiretroviral therapy service delivery in Africa, 2021
Full size table

Facility-based individual models

Barriers

Inconsistent model implementation [15, 52] and ARV drug stock-outs were organization-related barriers whereas the supply chain inconsistencies [14, 15, 52, 59, 67] were system-related barriers cited by the included studies. Provider-related barriers included a lack of information on model implementation [15], concern about patients’ returning to the clinic to report any problems [14, 52, 55], and fear of missing appointments in multimonth prescriptions [52]. Perceived lack of client-centeredness for the fast track refill model [24] and feasibility issue regarding large volumes of ART drug storage at home for multimonth prescriptions [55] were the patient-related inhibitors for model implementation.

Facilitators

From the patients’ side, a perceived higher need for privacy and confidentiality [14, 47, 59, 70], comprehensive health checks before taking necessary medications [49], reduced travel costs [14, 52, 53, 55, 68], reduced waiting time [14, 15, 52, 67, 70] and increased time for income-generating activities [55, 68] were reported as the enablers for model implementation. Reduction in staff workload [15, 47, 52, 53, 55, 67, 68] and decongestion of health facilities with clients [15, 47, 52, 53, 67] were supply-side facilitators commonly reported in the included studies for model implementation.

Out of facility-based individual models

Barriers

Demand-side barriers included fear of detachment from the health facility [59], patients’ lack of clarity on models [14], fear of missing doses because their medication was not delivered on time at home [15, 61] and fear of accidental disclosure [49]. Supply-side barriers included frequent drug stock-outs and supply chain problems [14], concerns about the need for providers’ monetary allowances and transport costs at communities [59], the difficulty in finding suitable space for outreach ART refills in rural settings [53], and additional burdens of data collection responsibilities [14].

Facilitators

From the patients’ side, reduced travel [14, 49], the convenience of accessing medications at home [49], and acceptability of the community pharmacy ART refill model were reported enablers for the implementation of models [44, 63]. Reduction in the overburdening of health facilities with clients [14] and better care for sicker patients [14] were cited as providers-related facilitators.

Client led group-based models

Barriers

Fear of stigma and discrimination for joining groups was a dominant patient-related barrier cited by included studies [14, 50, 59, 62]. Similarly, fear of detachment from the health facility [59], fear of clashing with peers [50], and dissatisfaction with the efficiency of drug pickups at the community level [14] were also patient-related barriers reported by the included studies. Medical record disorganization [14], the additional workload involved in packaging and labeling drugs for each member [59, 70], difficulty in finding competent and literate community client-led model leaders [59], and frequent changes in physical addresses among urban clients [59] were reported barriers for model implementation from the providers’ perspective.

Facilitators

From the patients’ side, lower transport costs [15, 56, 59, 62, 70] and increasing group and social support [15, 52, 56] were dominant enablers for model implementation. Reduction in the overburdening of health facilities with clients [15, 56, 62] and more time spent on patient data compilation and viral load testing [15, 62] were cited facilitators in model implementation from the providers’ side.

Healthcare worker-led group-based models

Barriers

From the patients’ perspective, inadvertent status disclosure [15, 22, 70], infrequent clinician visits [15], needing to find members to join their group [15], challenges with ART supply to adherence clubs [14], and patients’ lack of clarity about how models work [15] were among the barriers cited.

From the providers’ side, the reported barriers include providers’ concerns about insufficient medical recordkeeping [14], incorrect patient differentiation [14, 15], infrastructure (space) concerns [15, 22], and issue of transportation of the prepacked medication to the distribution sites [15, 22], staff shortages [15], and lack of compensation for staff working off-hours [15].

Facilitators

Reduced transportation costs [14, 70], promising health outcomes, particularly for patients who work [15], flexibility to pick up ARTs after the appointment date [15], and the possibility of family members picking up ARVs on behalf of patients [14] were the facilitators cited from the patients’ perspective. From the providers’ side, the facilitators reported by the included studies were improvement in adherence to treatment [14, 22], reduction in defaulter rate and tracking of loss to follow up [14, 22], reduction in the overburdening of health facilities with clients [14, 22], and increased opportunities for task-sharing among clinic staff [14, 22].

Barriers and facilitators common across DSD models implementation

The common reported facilitators for implementing four DSD models include reduced travel cost [14, 15, 49, 52, 53, 55, 56, 59, 62, 68, 70], improved or maintained adherence and retention [14, 15, 22, 56, 63, 67], reduction in staff workload [14, 15, 22, 47, 52, 53, 55, 62, 67, 68], and reduction in the overburdening of health facilities with clients [14, 15, 22, 47, 52, 53, 56, 62, 67].

The fear of stigma and discrimination [14, 15, 22, 47, 49, 50, 59, 62, 70], providers’ concern about patients’ ability to return to the clinic for other illnesses [14, 15, 52, 55, 56] and ARV drug stock-outs and supply chain inconsistencies [14, 15, 52, 59] were the commonly reported barriers for implementing four DSD models (Table 2).

Barriers and facilitators to the scale-up of DSD models for HIV treatment

Fifteen studies reported on DSD scale up. The barriers and facilitators identified in the included studies were summarized based on the health system dynamics framework in the following section (Table 3).

Table 3 Barriers and facilitators to scale-up of differentiated antiretroviral therapy service delivery in Africa, 2021
Full size table

Population (patient, community, and service provider)

Internalized stigma and discrimination were identified as barriers to scaling up DSD models for HIV treatment [47, 58, 59]. For example, lower-income and rural patients preferred community-based DSD models, whereas urban and wealthier patients preferred facility-based models due to a higher expressed need for privacy and confidentiality [59]. Another barrier reported was patients’ perception of the terms ‘unstable’ and ‘stable’ in DSD classification as provider-initiated stigma [59]. Stigma at the community level was a major impediment to community-based models [59]. Patients’ low literacy level was reported to be a barrier to enrollment in DSD models [58, 59]. The presence of patient education and peer support was found as a facilitator for the scaling up of DSD models [47].

The lack of acceptance from healthcare workers hampered the expansion of the adherence club intervention [35]. Scaling up adherence clubs in a facility was also hampered by the low energy held by providers to initiate or maintain change [38] and the providers’ perception of clubs not being core program work and having an increased workload when scaling up adherence clubs in a facility [38]. Low DSD delivery competence among healthcare workers has been identified as a bottleneck in service expansion [59]. The clinic staff’s low understanding of the benefits of the model and lack of trust that patients could be successfully managed outside of the traditional model of care was a barrier to successful community adherence club scale up [30].

Resources (time, finance, information, space, drug, and workforce)

The most common barriers to scaling up DSD models were a lack of financial, human, space, and drug resources as well as a lack of time to allow the client and/or provider buy-in [12, 16, 25, 35, 38, 40, 45, 47, 54, 58, 59]. Inadequate drug supply was reported as a major barrier in the DSD scale-up [38, 47, 59]. A consistent and flexible medication supply, on the other hand, has been found to help the DSD model scale up [45, 47]. Insufficient laboratory testing infrastructure [16], complaints about bad infrastructures such as small rooms and a scarcity of off-site places [38], and no available comfortable seating for adherence club meetings have all been reported as barriers [35]. Financial constraints have emerged as a major barrier to scaling up DSD models [12, 25, 40, 54, 59]. In a similar vein, inefficient utilization of existing resources has been identified as a challenge in model scale up [40]. Inadequate personnel levels have been cited as a barrier to the institutionalization of a pilot innovation [38]. The availability of functioning and reliable information systems aided model scale-up [45, 47].

Leadership and governance

The weak health system to maintain community ART group activities [58], lack of effort to formalize plans [38], gaps in pharmacy supply chain management [16], inadequate forecasting of healthcare worker needs within DSD models [16], inadequate training, coordination, and compensation of community healthcare workers [16, 35, 38, 59], and the clash between DSD and tuberculosis appointment spacing [59] were reported as the barriers for model scale up.

Inconsistency in model uptake and adoption [16], DSD not being implemented in lower health facilities [59], and DSD being provider-directed and lacking its client-centered goal [59] were also the reported barriers concerning leadership and governance aspects of DSD scale up efforts. In addition, the mix of the adherence club program with other HIV-negative patients [35], poor care linkages [47], inaccurate differentiating of patients based on clinical stability [16], and lack of clarity regarding the ongoing role of the steering committee [38] were reported barriers to DSD scale up.

In this review, the reported leadership and governance-related facilitators include a sequence of events for stepwise model implementation [57], availability of training, strong supervision and guidance related activities [25, 38, 45, 47], and remuneration for lay workers involved in supporting community-based ART delivery models [45]. Political will at all levels of the health system [38], policies and guidelines development [47], strong care linkages [47], clear referral mechanisms between the community and health facility [45], provision of free care to access HIV-related services [45] and availability of central chronic medicine dispensing and distribution program [26] were identified as critical facilitators.

The availability of a dedicated committee [38], the good approach of the adherence clubs steering committee while supporting individual health facilities offering adherence clubs [27], the collaborative implementation process [12], and increased focus on person-centered care [25] were reported facilitators in the leadership and governance dimension of DSD scale up. In addition, the presence of influential people in the steering committee [38], the deployment of a nurse champion [38], and the influence of early adopter clinics on other clinics providing ART service [38] were also reported as the leadership and governance related facilitators in model scale up.

Context

Extreme poverty, particularly in rural areas, was a barrier to the institutionalization of community-based models [58]. The running of patient groups of rotating ART refill pick-ups has been reported to be hampered by frequent changes in physical addresses (mobility) among urban clients [59]. Model flexibility was reported as the facilitator for scaling up the DSD models [25].

Discussion

Summary of the main results

Our scoping review aimed to identify the barriers and facilitators that influence the implementation and scale up of DSD interventions. The review identified several barriers and facilitators related to DSD model implementation and scale up. The synthesis showed that the overall influencing factors were clustered based on the four major types of DSD models for implementation, and according to the health system dynamics framework for scale up.

Implementation of DSD interventions

In this review, multiple barriers and facilitators were reported in the implementation of DSD models from both patient and provider perspectives. There is inconsistency in the influencing factors across the DSD models. This most likely reflects the differing circumstances and the effectiveness with which models were implemented as well as the inherent characteristics of each respective model. This is in agreement with a previous study which identified that different models place different demands on the health system and employ different techniques to break down barriers to care, therefore their functions may vary depending on the situation [73]. This has important implications for further policy development across health systems to accelerate the adaptation of DSD models in each setting.

The most often stated challenges to model implementation were staff shortages, providers’ lack of information on model implementation, and lack of staff clarity on eligibility criteria. These have policy implications to avail sufficient numbers and a diverse range of DSD workers, who are given the necessary training, skills, and tool to ensure that DSD is implemented with competence, responsiveness, and productivity. Low patient literacy and a lack of understanding of how the models work were also barriers to model implementation. This implies that extensive, comprehensive, and ongoing patient counseling and health promotion on DSD models are needed.

The availability of low or declining funding to support DSD models as well as limited logistics such as insufficient drug supply, lack of space for group-based models and lack of transportation of the prepacked medication to the distribution sites have created pressure for the adoption and implementation of HIV treatment models as reported from both patient and provider perspectives. This is consistent with a previous review [16].

The issues of stigma and discrimination were paramount concerns raised by patients which affect the implementation of respective DSD models. A previous study also identified stigma and discrimination as a barrier to ending AIDS by 2030 and achieving the 90-90-90 targets by 2020 [74]. This highlights much effort is needed to achieve the UNAIDS’s vision of zero discrimination toward people living with HIV by 2030.

Reduced patient travel costs, reduction in staff workload, and reduction in the overburdening of health facilities with clients and hence higher quality of care for unstable patients as well as improved or maintained adherence and retention were common reported facilitators for implementing DSD models for HIV treatment. These have important implications for health system performance (access, coverage, efficiency, equity, quality, safety, and sustainability) and overall impact (improved health, risk protection, and responsiveness) [75].

Scale-up of DSD interventions

The weak health systems, leadership, and governance were often reported as a barrier to DSD scale up. This could restrict the path to the Universal Health Care goal to be achieved by 2030. Moving closer to this goal requires the needed health services (such as DSD) to be available, of good quality, and affordable, which in turn requires attention to all the various components of a health system (infrastructure, medicines and medical products, health workers, health information, and health system financing). In this regard, good leadership and governance are critical and relevant to all the health system components as well as to the interactions between them [76]. A previous systematic review in sub-Saharan Africa also identified that a clear vision for institutionalizing DSD, innovative monitoring, and capacitating the health system with basic human and material resources are required to facilitate DSD sustainability [77]. Continuation of the existing weak health system, leadership, and governance however might impede the progress toward the next DSD 2.0 model, which integrates ART services with the most common vertical programs that require repeated follow-up: Tuberculosis prevention and treatment, family planning, and chronic non-communicable diseases as emphasized by WHO’s 2016 HIV guidelines [3].

The other most prominent factor influencing the scale-up of DSD interventions was the availability of the related resources. Lack of financial, human, space, and drug resources, as well as a lack of time to allow the client and/or provider buy-in, were often barriers to scale up. This could be detrimental to achieving the aim of DSD. According to the WHO’s consolidated guidelines on HIV prevention, testing, treatment, service delivery, and monitoring the success of DSD models in delivering ART depends on sufficient, reliable support and resources, such as a cadre of trained lay workers, a flexible and reliable medication supply, access to quality clinical management, and a reliable monitoring system for comprehensive client care [5].

The other common barriers to scaling up DSD models were the internalized stigma and discrimination issues attached to varied HIV treatment models. These two twin barriers might lead to a delay in the UNAIDS’ global partnership’s goal to reach zero HIV-related stigma and discrimination by 2030 [78].

Political will, policies and guidelines development, strong care linkages, clear referral mechanisms between the community, and health facility and provision of free care to access HIV-related services were facilitators for DSD model scale up. This has important implications for policymakers, program managers, and practitioners to enhance the existing leadership and governance efforts for continued expansion and maintenance of DSD models.

Strengths and limitations of the review

We emphasize that the strength of this review lies in drawing quantitative, qualitative, and mixed methods studies from a variety of evidence sources in a way not done previously, and we believe that our review still adds value to the current body of knowledge on DSD, by providing collated and comprehensive insights into the peer-reviewed scientific literature. The inclusion of grey literature makes this scoping review novel within this topic since the previous reviews were limited to published articles where valuable information from grey literature might have been overlooked. It is also a strength of this review that we have reviewed the perspectives of both patients and service providers that have not been adequately researched to date.

This review has limitations that should be taken into consideration when interpreting the results. First, the specific objective of all of the studies included was not the identification of barriers or enablers to DSD model implementation. The inconsistency noted was therefore expected, as barriers and enablers had to be extracted from the study reports, as thematic outputs. Second, as with the limitations of any scoping review, there is the possibility of incomplete retrieval of identified research due to the scope of the search terms and the databases searched. Third, there might be a probability of selection bias as only studies in the English language were included. Fourth, as this was a scoping review, we also did not perform a quality assessment therefore implications for practice or policy cannot be graded. Fifth, generalization of the study findings to settings other than Africa could be difficult due to variations in health systems and resource availability. It could even be difficult to generalize study findings to some settings in Africa since the continent encompasses a vast range of cultures and communities.

Conclusions

This scoping review identified a broad range of factors across multiple levels affecting the implementation and scale-up of different alternative DSD innovative interventions. There was an inconsistency in reporting factors by the included studies in this review where the same factor might be a facilitator in one context and a barrier in another context. The findings provide preliminary information to practitioners, program managers, decision makers, policymakers, educators, and researchers involved in the planning, design, implementation, scale-up, and evaluation of DSD models for HIV treatment. However, a major knowledge gap remains when it comes to understanding which contextual factors influence DSD implementation and scale-up in each setting. Hence, large-scale studies informed by implementation and scale up theories, models, and frameworks focusing on each DSD model in each healthcare setting are needed. In addition, there is a need for studies that explore the interrelationships between the various levels of barriers and facilitators identified in this review. Another unanswered question is related to the relative importance of each factor in specific DSD model implementation and scale up contexts which need to be explored by studies using prospective designs.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

AIDS:

Acquired Immunodeficiency Syndrome

ART:

Antiretroviral Therapy

ARV:

Antiretroviral

DSD:

Differentiated Service Delivery

HIV:

Human Immunodeficiency Virus

JBI:

Jonna Briggs Institute

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

UNAIDS:

The Joint United Nations Programme on HIV/AIDS

WHO:

World Health Organization

References

  1. HIV/AIDS _Fact Sheet. Available from: https://www.who.int/news-room/fact-sheets/detail/hiv-aid. Accessed 31 Dec 2020.

  2. Joint United Nations Programme on HIV/AIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. Geneva: Unaids; 2014.

    Google Scholar 

  3. World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach: World Health Organization; 2016.

    Google Scholar 

  4. Duncombe C, Rosenblum S, Hellmann N, Holmes C, Wilkinson L, Biot M, et al. Health I: reframing HIV care: putting people at the centre of antiretroviral delivery. Tropical Med Int Health. 2015;20(4):430–47.

    Article  Google Scholar 

  5. World Health Organization: Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach; 2021.

    Google Scholar 

  6. International AIDS Society: Differentiated care models. 2022. Accessed 5/11/2022 from https://www.differentiatedservicedelivery.org/Models/Treatment.

    Google Scholar 

  7. El-Sadr W. Differentiated service delivery: taking innovative delivery models to scale; 2018.

    Google Scholar 

  8. Ford N, Geng E, Ellman T, Orrell C, Ehrenkranz P, Sikazwe I, et al. Emerging priorities for HIV service delivery. PLoS Med. 2020;17(2):e1003028.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Ehrenkranz P, Grimsrud A, M R. AIDS: differentiated service delivery: navigating the path to scale. Curr Opin HIV AIDS. 2019;14(1):60–5.

    Article  PubMed  Google Scholar 

  10. Glasgow RE, Vinson C, Chambers D, Khoury MJ, Kaplan RM, Hunter CJ. National institutes of health approaches to dissemination and implementation science: current and future directions. Am J Public Health. 2012;102(7):1274–81.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Organization WH. Nine steps for developing a scaling-up strategy: World Health Organization; 2010.

    Google Scholar 

  12. Flamig K, Decroo T, van den Borne B, van de Pas R. ART adherence clubs in the Western cape of South Africa: what does the sustainability framework tell us? A scoping literature review. J Int AIDS Soc. 2019;22(3):e25235.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Hagey JM, Li X, Barr-Walker J, Penner J, Kadima J, Oyaro P, et al. Differentiated HIV care in sub-Saharan Africa: a scoping review to inform antiretroviral therapy provision for stable HIV-infected individuals in Kenya. AIDS Care. 2018;30(12):1477–87.

    Article  PubMed  Google Scholar 

  14. Kuchukhidze S, Long L, Pascoe S, Huber A, Nichols B, Fox M. Differentiated models of service delivery (DSD) for antiretroviral treatment of HIV in sub-Saharan Africa: a review of the gray literature as of June 2019. In: AMBIT Project Report.

  15. Long L, Kuchukhidze S, Pascoe S, Nichols B, Cele R, Govathson C: Differentiated service delivery models for antiretroviral treatment of HIV in Sub-Saharan Africa: a rapid systematic review. 2020. Cited 2020 Nov 10.

    Google Scholar 

  16. Roy M, Bolton Moore C, Sikazwe I, Holmes CB. A review of differentiated service delivery for HIV treatment: effectiveness, mechanisms, targeting, and scale. Curr HIV/AIDS Rep. 2019;16(4):324–34.

    Article  PubMed  Google Scholar 

  17. Peters MDJGC, McInerney P, Munn Z, Tricco AC, Khalil H. JBI manual for evidence synthesis. In: Chapter 11: scoping reviews; 2020.

    Google Scholar 

  18. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73.

    Article  PubMed  Google Scholar 

  19. JBI Manual for Evidence Synthesis. https://wiki.joannabriggs.org/display/MANUAL.

  20. van Olmen J, Criel B, Van Damme W, Marchal B, Van Belle S, Van Dormael M, Hoerée T, Pirard M, Kegels G: Analysing health systems to make them stronger. In.: ITGPress; 2010.

    Google Scholar 

  21. Peters M, Godfrey C, McInerney P, Soares C, Khalil H, Parker D. The Joanna Briggs institute reviewers’ manual 2015: methodology for JBI scoping reviews; 2015.

    Google Scholar 

  22. Tshuma N, Mosikare O, Yun JA, Alaba OA, Maheedhariah MS, Muloongo K, et al. Adherence: acceptability of community-based adherence clubs among health facility staff in South Africa: a qualitative study. Patient Prefer Adherence. 2017;11:1523.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Mukumbang FC, Bv W, Sv B, Marchal B. 'At this [adherence] club, we are a family now': a realist theory-testing case study of the antiretroviral treatment adherence club, South Africa. Southern Afr J HIV Med. 2019;20(1):a922.

    Google Scholar 

  24. Ndlovu S. Comparison of patient experiences in three differentiated antiretroviral delivery models in a public health care facility; 2020.

    Google Scholar 

  25. Sharer M, Davis N, Makina N, Duffy M, Eagan S. Differentiated antiretroviral therapy delivery: implementation barriers and enablers in South Africa. J Assoc Nurses AIDS Care. 2019;30(5):511.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Liu L, Christie S, Munsamy M, Roberts P, Pillay M, Shenoi S, et al. Expansion of a national differentiated service delivery model increases access to treatment for HIV and other chronic conditions in South Africa; 2021.

    Book  Google Scholar 

  27. Wilkinson L, Harley B, Sharp J, Solomon S, Jacobs S, Cragg C, et al. Expansion of the adherence Club model for stable antiretroviral therapy patients in the cape metro, South Africa 2011-2015. Tropical Med Int Health. 2016;21(6):743–9.

    Article  Google Scholar 

  28. Dudhia R, AJP K. Experiences of participating in an antiretroviral treatment adherence club. Psychol Health Med. 2015;20(4):488–94.

    Article  PubMed  Google Scholar 

  29. Venables E, Towriss C, Rini Z, Nxiba X, Solomon S, Cassidy T, et al. If I’m not in the club, I have to move from one chair to another. In: A qualitative evaluation of patient experiences of adherence clubs in Khayelitsha and Gugulethu, South Africa 9th IAS Conf HIV Sci. Paris; 2017.

  30. Grimsrud A, Sharp J, Kalombo C, Bekker LG, Myer L. Implementation of community-based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa. J Int AIDS Soc. 2015;18(1):19984.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Wilkinson L, Harley B, Jacobs S, Cragg C, Kriel E, Solomon S, et al. Implementation scale up of the adherence Club model of care to 30,000 stable antiretroviral therapy patients in the cape metro: 2011-2014. J Int AIDS Soc. 2015;18:29–30.

    Google Scholar 

  32. Keene CM, Zokufa N, Venables EC, Wilkinson L, Hoffman R, Cassidy T, et al. Only twice a year’: a qualitative exploration of 6-month antiretroviral treatment refills in adherence clubs for people living with HIV in Khayelitsha, South Africa. BMJ Open. 2020;10(7):e037545.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Venables E, Towriss C, Rini Z, Nxiba X, Cassidy T, Tutu S, et al. Patient experiences of ART adherence clubs in Khayelitsha and Gugulethu, Cape Town, South Africa: a qualitative study. PLoS One. 2019;14(6):e0218340.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. De Jager GA, Crowley T, Esterhuizen TM. Patient satisfaction and treatment adherence of stable human immunodeficiency virus-positive patients in antiretroviral adherence clubs and clinics. Afr J Prim Health Care Fam Med. 2018;10(1):e1–8.

    Article  PubMed  Google Scholar 

  35. Mukumbang FC, Marchal B, Van Belle S, van Wyk B. "Patients are not following the [adherence] Club rules anymore": a realist case study of the antiretroviral treatment adherence Club, South Africa. Qual Health Res. 2018;28(12):1839–57.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Mudavanhu M, West NS, Schwartz SR, Mutunga L, Keyser V, Bassett J, et al. Perceptions of community and clinic-based adherence clubs for patients stable on antiretroviral treatment: a mixed methods study. AIDS Behav. 2020;24(4):1197–206.

    Article  PubMed  Google Scholar 

  37. Bock P, Gunst C, Maschilla L, Holtman R, Grobbelaar N, Wademan D, et al. Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa. J Int AIDS Soc. 2019;22(10).

  38. MacGregor H, McKenzie A, Jacobs T, Ullauri AJG. Health: scaling up ART adherence clubs in the public sector health system in the Western cape, South Africa: a study of the institutionalisation of a pilot innovation. Glob Health. 2018;14(1):1–18.

    Article  Google Scholar 

  39. Dorward J, Msimango L, Gibbs A, Shozi H, Tonkin-Crine S, Hayward G, et al. Understanding how community antiretroviral delivery influences engagement in HIV care: a qualitative assessment of the centralised chronic medication dispensing and distribution programme in South Africa. BMJ Open. 2020;10(5):e035412.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Mukumbang FC, Orth Z, Van Wyk B. Aystems: what do the implementation outcome variables tell us about the scaling-up of the antiretroviral treatment adherence clubs in South Africa? A document review. Health Res Policy Syst. 2019;17(1):1–12.

    Article  Google Scholar 

  41. Davey D, Serrao C, Prins M, Feinberg M, Pooe D, Femi O. Who were the patients on differentiated care? Uptake of HIV differentiated care models for patients on antiretroviral therapy in South Africa. Abstract WEPEE756. In: 22nd international AIDS conference, Amsterdam; 2018.

    Google Scholar 

  42. Laga M: Community-based ART in sub-Saharan Africa: lessons learnt from community ART groups in Tete province, Mozambique.

  43. Rasschaert F, Decroo T, Remartinez D, Telfer B, Lessitala F, Biot M, et al. Adapting a community-based ART delivery model to the patients’ needs: a mixed methods research in Tete, Mozambique. BMC Public Health. 2014;14:364.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Asieba IO, Oqua DA, Wutoh AA, Agu KA, Omeh OI, Adeyanju ZA, et al. Antiretroviral therapy in community pharmacies - implementation and outcomes of a differentiated drug delivery model in Nigeria. Res Soc Adm Pharm. 2021;17(5):842–9.

    Article  Google Scholar 

  45. Bemelmans M, Baert S, Goemaere E, Wilkinson L, Vandendyck M, van Cutsem G, et al. Community-supported models of care for people on HIV treatment in sub-S aharan A frica. Tropical Med Int Health. 2014;19(8):968–77.

    Article  Google Scholar 

  46. Ssonko C, Gonzalez L, Mesic A, da Fonseca MS, Achar J, Safar N, et al. Delivering HIV care in challenging operating environments: the MSF experience towards differentiated models of care for settings with multiple basic health care needs. J Int AIDS Soc. 2017;20(Suppl 4):21654.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Duffy M, Sharer M, Davis N, Eagan S, Haruzivishe C, Katana M, et al. Differentiated antiretroviral therapy distribution models: enablers and barriers to universal HIV treatment in South Africa, Uganda, and Zimbabwe. J Assoc Nurses AIDS Care. 2019;30(5):e132.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Huber A, Pascoe S, Nichols BE, Long L, Kuchukhidze S, Phiri B, et al. Sifferentiated service delivery models for HIV treatment in Malawi, South Africa, and Zambia: a landscape analysis; 2020.

    Google Scholar 

  49. Adjetey V, Obiri-Yeboah D, B D. Differentiated service delivery: a qualitative study of people living with HIV and accessing care in a tertiary facility in Ghana. BMC Health Serv Res. 2019;19(1):1–7.

    Article  Google Scholar 

  50. Kizito O, Sabiti LJCM. Factors associated with uptake of community client-led ART delivery model at Mulago adult HIV clinic _ Mulago National Referral Hospital. Cogent Med. 2021;8(1):1896427.

    Article  Google Scholar 

  51. Zakumumpa H, Bennett S, Ssengooba F. Modifications to ART service delivery models by health facilities in Uganda in promotion of intervention sustainability: a mixed methods study. Implement Sci. 2017;12(1):45.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Prust ML, Banda CK, Callahan K, Nyirenda R, Chimbwandira F, Kalua T, et al. Patient and health worker experiences of differentiated models of care for stable HIV patients in Malawi: a qualitative study. PLoS One. 2018;13(7):e0196498.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Phiri K, McBride K, Siwale Z, Hubbard J, Bardon A, Moucheraud C, et al. Provider experiences with three-and six-month antiretroviral therapy dispensing for stable clients in Zambia. AIDS Care. 2021;33(4):541–7.

    Article  PubMed  Google Scholar 

  54. Rasschaert F, Telfer B, Lessitala F, Decroo T, Remartinez D, Biot M, et al. A qualitative assessment of a community antiretroviral therapy group model in Tete, Mozambique. PLoS One. 2014;9(3):e91544.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Hubbard J, Phiri K, Moucheraud C, McBride K, Bardon A, Balakasi K, et al. A qualitative assessment of provider and client experiences with 3-and 6-month dispensing intervals of antiretroviral therapy in Malawi. Glob Health Sci Pract. 2020;8(1):18–27.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Bochner AF, Meacham E, Mhungu N, Manyanga P, Petracca F, Muserere C, et al. The rollout of community ART refill groups in Zimbabwe: a qualitative evaluation. J Int AIDS Soc. 2019;22(8):e25393.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Decroo T, Lara J, Rasschaert F, Bermudez-Aza E, Couto A, Candrinho B, et al. Scaling up community ART groups in Mozambique. Int STD Res Rev. 2013;12:49–59.

  58. Rasschaert F, Decroo T, Remartinez D, Telfer B, Lessitala F, Biot M, et al. Sustainability of a community-based anti-retroviral care delivery model - a qualitative research study in Tete, Mozambique. J Int AIDS Soc. 2014;17(1):18910.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Zakumumpa H, Rujumba J, Kwiringira J, Katureebe C, Spicer N. Understanding implementation barriers in the national scale-up of differentiated ART delivery in Uganda. BMC Health Serv Res. 2020;20(1):1–16.

    Article  Google Scholar 

  60. Pellecchia U, Baert S, Nundwe S, Bwanali A, Zamadenga B, Metcalf CA, et al. “We are part of a family” Benefits and limitations of community ART groups (CAGs) in Thyolo, Malawi: a qualitative study. J Int AIDS Soc. 2017;20(1):21374.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Geldsetzer P, Francis JM, Ulenga N, Sando D, Lema I, Mboggo E, et al. The acceptability and feasibility of community health worker-led home-delivery of antiretroviral therapy: early findings from a health systems trial in Dar es Salaam, Tanzania; 2017.

    Google Scholar 

  62. Mashungu V, Munkuli J, Khembo W, Kumani B, Nkawu B, Fatti G. Acceptability of community differentiated models of care: a patient and service provider’s perspective on community art refill groups in Zimbabwe. Abstract WEPEE759. In: 22nd international AIDS conference. Amsterdam; 2018.

  63. Mulenga HB, Muhau M, Kateule K. Differentiated service delivery using a “community pharmacy ART drug pickup” model: an evaluation from Lusaka, Zambia. Abstract MOPED623. In: 10th IAS conference on HIV science. Mexico City; 2019.

  64. Roy M, Bolton C, Sikazwe I, Mukumbwa-Mwenechanya M, Efronson E, Somwe P. Implementation and effectiveness of urban adherence clubs in Zambia. Abstract FRAE0104. In: 22nd international AIDS conference. Amsterdam; 2018.

  65. Pasipamire L, Kerschberger B, Zabsonre I, Ndlovu S, Sibanda G, Mamba S, et al. Implementation of combination ART refills models in rural Swaziland. In: Journal of THE international AIDS Society. SOUTHERN GATE: JOHN WILEY & SONS LTD THE ATRIUM; 2016.

    Google Scholar 

  66. Prust M, Banda C, Nyirenda R, Chimbwandira F, Kalua T, Jahn A, et al. Multi-month refills of antiretroviral drugs for stable patients in Malawi: assessing accuracy in the application of eligibility criteria at the health facility level. In: Journal Of the international aids society. SOUTHERN GATE: JOHN WILEY & SONS LTD THE ATRIUM; 2017. p. 20–0.

    Google Scholar 

  67. Attah M, Mohammed A, Hassan S. Nigeria ARV multimonth scripting: impact on public health service delivery, infrastructure and supply chain management systems across “high volume” ART clinics. Abstract WEPEE740. In: 22nd international AIDS conference. Amsterdam; 2018.

  68. Hubbard J, Phiri K, Moucheraud C, McBride K, Bardon A, Balakasi K, Lungu E, Dovel K, Kakwesa G, Hoffman RM: Understanding implementation from provider and client perspectives: The INTERVAL study on multi-month ART dispensing in Malawi.

  69. Roy M, Mukumbwa-Mwenechanya M, Efronson E, Lumpa M, Sharma A, Sikazwe I, et al. Uptake and adaptation of community adherence groups in Zambia. In: Poster presentation at the conference on retroviruses and opportunistic infections. Seattle; 2017. p. 13–6.

  70. Christ B, van Dijk JH, Ballif M, Nyandoro T, Reichmuth ML, Mukondwa WR, et al. Differentiated antiretroviral therapy delivery in rural Zimbabwe: availability, needs and challenges; 2020.

    Google Scholar 

  71. Zakumumpa H, Makobu K, Wilbrod N, Maniple E. A mixed-methods evaluation of the uptake of novel differentiated ART delivery models in a national sample of health facilities in Uganda; 2021.

    Google Scholar 

  72. Prust ML, Banda CK, Nyirenda R, Chimbwandira F, Kalua T, Jahn A, et al. Multi-month prescriptions, fast-track refills, and community ART groups: results from a process evaluation in Malawi on using differentiated models of care to achieve national HIV treatment goals. J Int AIDS Soc. 2017;20:21650.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Geng EH, Holmes CB. Research to improve differentiated HIV service delivery interventions: Learning to learn as we do. PLoS Med. 2019;16(5):e1002809.

    Article  PubMed  PubMed Central  Google Scholar 

  74. Wirawan DN. Stigma and discrimination: barrier for ending AIDS by 2030 and achieving the 90-90-90 targets by 2020; 2019.

    Google Scholar 

  75. Organization WH. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies: World Health Organization; 2010.

    Google Scholar 

  76. World Health Organization: Health systems governance for universal health coverage action plan: department of health systems governance and financing. In.: World Health Organization; 2014.

    Google Scholar 

  77. Okere NE, Lennox L, Urlings L, Ford N, Naniche D, de Wit TFR, et al. Exploring sustainability in the era of differentiated HIV service delivery in Sub-Saharan Africa: a systematic review. J Acquir Immune Defic Syndr. 2021;87(4):1055.

    Article  PubMed  PubMed Central  Google Scholar 

  78. Global Partnership for Action to Eliminate All Forms of HIV-Related Stigma and Discrimination. https://www.unaids.org/en/resources/documents/2018/global-partnership-hiv-stigma-discrimination.

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Acknowledgments

We acknowledge the authors of the studies included in this review.

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  1. Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia

    Yihalem Abebe Belay

  2. Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Yihalem Abebe Belay, Mezgebu Yitayal & Asmamaw Atnafu

  3. Department of Accounting, Finance, and Economics, Griffith University, Brisbane, Australia

    Fitalew Agimass Taye

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All authors developed the literature search strategy. YAB, FAT, and MY conducted the literature searches. YAB, MY, and AA extracted the data. The manuscript was drafted by YAB and FAT. All authors read and approved the final manuscript.

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Belay, Y.A., Yitayal, M., Atnafu, A. et al. Barriers and facilitators to the implementation and scale up of differentiated service delivery models for HIV treatment in Africa: a scoping review. BMC Health Serv Res 22, 1431 (2022). https://doi.org/10.1186/s12913-022-08825-2

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