Effectiveness and experiences with differentiated service delivery of HIV care in Kisumu County, Kenya: A mixed methods study, 2014-2021.

The adoption of the test and treat policy by the World Health Organization (WHO) in 2015 led to an unprecedented increase in the number of people living with HIV (PLHIV) enrolling into HIV treatment, thereby increasing the burden on HIV service delivery. To compensate, WHO endorsed the Differentiated Service Delivery (DSD) approach to reduce the burden on the health care system and therefore support attainment of the UNAIDS 95-95-95 goals by 2030. This study examined clinical outcomes among clients enrolled in the DSD models and examined health care worker and client experiences of the DSD approach. A client-level pre-post study was conducted in 14 Ministry of Health (MOH) facilities in Kisumu County from October 2014 - March 2021 to examine retention and viral load suppression (<1000 copies/mL) in a cohort of stable clients aged 20 years and above at three time points: immediately preceding DSD start (pre-DSD; 2014-2016), 12 months post-DSD implementation (midline), and 24 months post-DSD (endline). Focus group discussions (FGDs) were conducted to assess DSD experiences among a sample of adult clients and health care workers. Findings from the pre-post analysis showed a significant increase in retention at 12 months (99.2%) and 24 months (98.9%) compared to pre-DSD (86.4%; p < 0.001). The predominant themes shared by clients and healthcare workers in FGDs were high satisfaction with DSD due to the efficiency of services, improved staff attitudes, and reduced clinic workload. Clients also expressed a strong preference for facility-based models owing to perceived stigma and privacy concerns associated with community DSD models. This study provides important insights on the promising effectiveness of DSD models on sustained retention on ART and viral suppression and the acceptability of this modality for client-centered HIV care.