Makerere University, School of Public Health, Kampala, Uganda.
Makerere University, School of Medicine, Kampala, Uganda.
BMC Health Serv Res. 2020 Mar 17;20(1):222. doi: 10.1186/s12913-020-5069-y.
Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)'s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients' and HIV service managers' perspectives on barriers to implementation of Differentiated ART service delivery in Uganda.
We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context.
Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations.
Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups.
This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).
自世界卫生组织（WHO）2016 年发布具有里程碑意义的指南以来，一些国家已在全国范围内推出了差异化服务提供（DSD）抗逆转录病毒治疗（ART），但很少有研究评估实施后的结果。本研究的目的是探讨乌干达实施差异化 ART 服务提供的障碍，从患者和 HIV 服务管理人员的角度进行分析。
我们采用了定性描述性设计，涉及 124 名参与者。2019 年 4 月至 6 月期间，我们在乌干达六个艾滋病毒负担沉重的（坎帕拉、卢韦罗、瓦基索、姆巴莱、布达迪里、布伦比利）选定地区进行了 76 次定性访谈，其中包括国家一级艾滋病毒规划管理人员（n=18）、地区卫生团队领导（n=24）、PEPFAR 实施组织代表（n=11）、ART 诊所负责人（n=23）。在案例研究地区，我们还与参加 DSD 模式的患者进行了 6 次焦点小组讨论（48 名参与者）。数据采用主题方法进行分析，主题方法受到多层面分析框架的指导：个人层面因素；卫生系统因素；社区因素；和背景。
我们的数据表明，在 DSD 实施过程中遇到了多种障碍。个人层面：报告称，个体化耻辱感以及稳定患者脱离医疗机构的恐惧，是基于社区模式下的障碍。社会经济地位被认为对患者选择 DSD 模式有影响。卫生系统层面：发现卫生工作者在 DSD 提供方面的培训不足以及多剂量 ART 配药的供应链障碍，是制约因素。患者认为目前的 DSD 模型选择是提供者密集型的，而不是以患者为中心的。社区层面：发现社区层面的耻辱感以及提供者充分运作社区药物取货点的资金不足，是限制因素。
据报道，城市客户经常更改物理地址，这阻碍了定期 ART 续药患者群体的运转。
这是乌干达自 2017 年首次推出全国 DSD 以来，首次对其实施情况进行多方利益攸关方评估。需要从需求侧（解决与艾滋病毒相关的耻辱感、社区参与）和供应侧（加强 ART 供应链能力、增加社区模式的资金、进一步改善 DSD 方案设计以提高以患者为中心）进行多层次干预，以加快乌干达 DSD 的进一步实施。
