Of the 8 million people in South Africa living with HIV, only 56% are on antiretroviral therapy (ART), and 45% are virally suppressed, substantially below the UNAIDS goal of 73%. Detectable viral load results in HIV-associated morbidity and mortality, and HIV transmission. Patient barriers to care, such as missed wages, transport costs, and long wait times for clinic visits and ART refills, are associated with detectable viral load. HIV differentiated service delivery (DSD) has simplified ART delivery: incentives, multi-month scripts, fast-track ART, and community or home ART delivery motivate clients, reduce the frequency of clinic visits, and decongest clinics. DSD is standard for clients who achieve viral suppression and engage in care; however, DSD needs adaptation to serve clients who are not succeeding. Indeed, persons who are not engaged in care arguably need simplified, client-centered approaches even more than those who can successfully engage.

A suite of adaptive DSD strategies, including incentives strategies, community-based ART, and home delivery, have been tested among stable clients with viral suppression. Lottery incentives effectively change short-term behavior, increasing ART initiation.Community-based and home ART delivery increase ART coverage and simplify ART access overcoming clinic barriers11. For stable clients, these DSD activities are as effective as clinic-based care in terms of achieving and maintaining viral suppression, although among stable clients they have not shown superiority in viral suppression or cost savings. In contrast, DSD has the potential to improve rates of viral suppression and retention in care and save costs among persons not engaged in care. There is great potential that DSD systems can be client-responsive and system-efficient for subgroups requiring additional services, matching services with client needs. A sequential, comprehensive package of DSD approaches, with each step increasing the intensity of service provision - adaptive DSD - has not been tested to determine the proportion and characteristics of persons who would achieve viral suppression and retention in care and to estimate the cost-effectiveness and budget impact.

To increase population level viral suppression, persons with detectable viral load need responsive DSD interventions. A Sequential Multiple Assignment Randomized Trial (SMART) design facilitates evaluation of a stepped, adaptive approach to achieving viral suppression with 'right-sized' interventions. The investigators are an experienced team and propose to build on the strong partnerships to sequentially test adaptive DSD strategies for persons with detectable viral load and/or not engaged in care: incentives, community-based ART, and home delivery. As the Center for Community Based Research, the investigators maintain strong connections with stakeholders including department of health, traditional leaders and ward counsellors throughout the Greater Edendale Area (GEA) and the Vulindlela sub-district of the uMgungundlovu District Municipality. Due to the size of the recruitment target, this work will centre around the Caluza clinic but will extend into other parts of GEA and sub-district of Vulindlela over the course of recruitment. The aim is to identify the most effective and efficient HIV care delivery strategies.