Table 3 Barriers and facilitators to scale-up of differentiated antiretroviral therapy service delivery in Africa, 2021
Factors | Barriers | Facilitators |
|---|---|---|
Client, community, and service provider | ▪ Income and residence [59] ▪ Patients’ perception of the terms ‘unstable’ and ‘stable’ in DSD classification as provider stigma [59] ▪ Stigma at the community level [59] ▪ Patients’ low literacy [58, 59] ▪ The lack of buy-in from healthcare workers at both the facility and community levels [35] ▪ The low energy required of providers to initiate or maintain change [38] ▪ The ART program staff’s perception of clubs not being core program work [38] ▪ Healthcare workers’ perception of having an increased workload when scaling up adherence clubs in a facility [38] ▪ Low DSD delivery competence among health workers [59] ▪ Serving patients in community-based models was not seen as the facility’s responsibility [30] | ▪ The presence of patient education and peer support [47] |
Resources (time, finance, information, space, drug, and workforce) | â–ª Inadequate drug supply [38, 47, 59] â–ª Insufficient laboratory testing infrastructure [16] â–ª 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 [35] â–ª Financial constraints [12, 25, 40, 54, 59] â–ª In-efficient utilization of existing resources [40] â–ª Inadequate number of staff [38] â–ª Lack of time to allow the client and/or provider buy-in [25] | â–ª A consistent and flexible medication supply [45, 47] â–ª The availability of functioning and reliable information system s[45, 47] |
Leadership and governance | ▪ Weak health system [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] ▪ The clash between DSD and tuberculosis appointment spacing [59] ▪ Inconsistency in model uptake and adoption across models [16] ▪ Problems of capacity related to the composition of the chronic dispensing unit system and the pharmaceutical dimension of clubs [38] ▪ DSD not implemented in lower health facilities [59] ▪ DSD lacked client-centeredness as designed [59] ▪ 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] ▪ Lack of clarity regarding the ongoing role of the steering committee [38] | ▪ 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] ▪ Availability of central chronic medicine dispensing and distribution program [26] ▪ A sequence of events for stepwise model implementation [57] ▪ Availability of training, strong supervision, and guidance related activities [25, 38, 45, 47] ▪ Remuneration for lay workers involved in supporting community-based models [45] ▪ Availability of a dedicated committee [38] ▪ The better approach of the clubs’ steering committee to guide adherence club eligibility and structure [27] ▪ The collaborative implementation process [12] ▪ Increased focus on person-centered care [25] ▪ The presence of influential people in the steering committee [38] ▪ Deployment of a nurse champion [38] ▪ The influence of early adopter clinics on other clinics providing ART service [38] |
Context | â–ª Extreme poverty conditions, particularly in rural areas [58] â–ª Frequent changes in physical addresses (mobility) among urban clients [59] | â–ª Model flexibility [25] |