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

Barriers to implementation

❖ Health facilities implement multimoth scripting refill length inconsistently [15, 52]

❖ Fast track refill lack patient-centeredness [24]

❖ Providers concerned with the perceived inability to provide adequate care could feel disconnected from their patients and could miss “silent issues”, doubted patient abilities to adhere to medication [47]

❖ Multimoth scripting could cause patients to be more likely to miss appointments because of a long length of time between schedules [52]

❖ Patients were not coming back to the clinic promptly to report any problems [14, 52, 55]

❖ At multimoth scripting initiation, the number of ARV issues to patients increased; these lead to short term supply risk that required a temporary slowdown of its implementation [67]

❖ Providers lack of information on model implementation [15]

❖ Antiretroviral drug stock-outs and supply chain inconsistencies [14, 15, 52, 59]

❖ Providers were concerned with an increased possibility of medications being misused by patients [52], antiretroviral sharing with family or friends making pill count difficult [14, 55]

❖ Feasibility at the clients level regarding large volume of ART drug storage at home [55]

❖ Patients were concerned with the fear of inadvertent disclosure due to having to store large quantities of medication at home and concerns regarding the safety and storage of medication for prolonged periods at home [14, 47]

▪ Fear of detachment from the formal health system [59]

▪ Fears that prolonged periods without being seen by health workers would imply an inability to access comprehensive care including in the event of opportunistic infections such as Tuberculosis [59]

▪ Patients lack clarity with regard to how models work [14]

▪ Some patients reported a missing dose because their medication was not delivered at home on time [15, 61]

▪ Fear of accidental disclosure and its associated stigma and discrimination [49]

▪ Need for vehicles and fuel to transport health workers into communities [59]

▪ Need for health worker monetary allowances during community visits [59]

▪ The difficulty in finding suitable physical infrastructure in rural settings to designate as outreach points for ART refills [59]

▪ The additional burden due to data collection responsibilities [14]

▪ Frequent drug stock-outs and supply chain problems [14]

▪ Expensive to implement and yet facilities had not received adequate funding and resource facilitation from donors and the government [71]

➢ Patients prefer meeting with the healthcare provider one-to-one to protect confidentiality [14]

➢ Fear of stigma, discrimination, and losing respect as reasons for not joining groups [50, 59, 62]

➢ Some clients expressed a lack of cooperation among individuals as the likely reason why some patients fear forming the community client lead antiretroviral distribution groups since they do not know each other at the beginning and they fear clashing in the community [50]

➢ Some clients reported fear of bad doing through someone else handling their medication as one of the reasons for not joining client lead groups [62]

➢ Fear of detachment from the formal health system [59]

➢ Some patients were dissatisfied with the efficiency of drug pickups [14]

➢ Group leaders of patient groups expressed difficulty in sustaining transport costs to facilities to pick drugs on behalf of their colleagues, and have concerns about identifying ART refill packages for each of their members [59]

➢ Lack of sufficient resources to perform what is expected from them for DSD [14, 59]

➢ Disorganization of medical records [14]

➢ The additional workload involved in packaging and labeling antiretrovirals for each member while decentralization of drug delivery to communities [59, 70]

➢ Difficulty in finding competent and literate leaders of community client lead ART distribution groups [59]

➢ Patients may not seek needed care [15, 56]

➢ Frequent changes in physical addresses among urban clients impeded the running of patient groups of rotating ART refill pick-ups [59]

➢ Low patient literacy of DSD models [59]

• Inadvertent status disclosure [15, 22, 70]

• Infrequent clinician visits and needing to find members to join their group [15]

• Challenges to ART supply to the adherence clubs [14]

• Patients lack clarity with regard to how models work [15]

• Inadequate medical recordkeeping [14]

• An increase in the probability of many patients defaulting from picking up their medication if adherence clubs are implemented in community venues [22]

• Increased burden on staff [14, 15]

• Incorrect patient differentiation [14]

• Security of medication [15, 22]

• ART storage conditions [15, 22]

• Infrastructure (space) concerns [15, 22]

• Providers concerned with the transportation of the prepacked medication to the distribution sites [15, 22]

• Staff shortage [15]

• Lack of compensation for staff working off-hours [15]

• Lack of staff clarity on eligibility criteria [15]

• Lack of staff clarity on the rationale for referral back to the standard of care [15]

Facilitators to implementation

❖ Having comprehensive health checks before taking necessary medications [49]

❖ Perceived higher need for privacy and confidentiality by clients especially for urban and high-income categories [59, 71]

❖ Reduced travel cost [14, 52, 53, 55, 68]

❖ Reduced waiting time [14, 15, 52, 67, 70]

❖ Flexible characteristics of the FTR model(patients could also collect antiretroviral drugs outside of working hours including evening time) [24]

❖ Alleviate issues with absenteeism from work for clinic appointments [52]

❖ Increased time for income-generating activities [55, 68]

❖ Improved freedom for employment and family travel [14]

❖ Improved or maintained adherence [15, 67]

❖ Improved overall patient satisfaction with clinic services [15, 67]

❖ Encourage patients not in care to seek services [52]

❖ A greater sense of personal freedom and normalcy [55, 68]

❖ Having no reports of antiretroviral trade or misuse and unwanted HIV disclosure, and antiretrovirals are easily and safely stored at home [14]

❖ Reduction in staff workload [15, 47, 52, 53, 55, 67, 68]

❖ Reduction in the overburdening of health facilities [15, 47, 52, 53, 67]

❖ Requiring least resource inputs (fast track refill is most practical to implement) [71]

❖ Having no reports of antiretrovirals shortages or expiration [14]

▪ Reduced patient travel cost [14, 49]

▪ Reduction in the overburdening of health facilities [14]

▪ Better care for sicker patients [14]

▪ Role in continuation of care at community pharmacy [44]

▪ Support care retention for established, stable patients on ART [63]

▪ The convenience of accessing medications in the comfort of their own home [49]

▪ Overcame material barriers to attending clinics, changed the meanings associated with collecting ART, and was less disruptive to other social practices in clients’ lives [39]

➢ Increasing group and social support [15, 52, 56]

➢ Reduction in the overburdening of health facilities and higher quality of care for unstable patients [15, 56, 62]

➢ More time spent on patient data compilation and viral load testing to improve monitoring [15, 62]

➢ Reduced transport costs [15, 56, 59, 62, 70]

➢ Have an important role in adherence and defaulter tracing for improved retention [15, 56]

➢ New client lead group members anticipate the benefit of a reduction in facility visits thereby allowing increased focus on productive activities, and group support through livelihood projects, adherence, and defaulter tracing thereby improving retention, lifestyles, and psychological well-being [62]

• Forming community-based patient support structures in the form of support groups and open the door for patient empowerment and self-management [14, 22, 42]

• Reduced transport costs [14, 70]

• Better linkage to care [14, 22]

• Improvement in adherence to treatment [14, 22]

• Reduction in defaulter rate and tracking of lost to follow up [14, 22]

• Facility decongestion [14, 22]

• Reduction of provider burden [14, 22]

• Give more opportunities for task-sharing between clinic staff [14, 22]

• Promising health outcomes, especially convenient for patients who work [15]

• Flexibility to pick up ARTs after the appointment date [15]

• Models that allow for family members to pick up antiretrovirals on behalf of the patients are especially convenient [14]

• Reduced sense of stigma [14, 22]