Are HIV treatment clients offered a choice of differentiated service delivery models? Evidence from Malawi, South Africa, and Zambia
Authors: Mokhele Idah , Ntjikelane Vinolia , Scott Nancy , Kaiser Jeanette L. , Morgan Allison , Huber Amy , Mokgethi Oratile , Tchereni Timothy , Phiri Wyness , Kamanga Aniset , Haimbe Prudence , Lumano-Mulenga Priscilla , Nyirenda Rose , Pascoe Sophie , Rosen Sydney 
Published: December 2024

Purpose

Differentiated service delivery (DSD) models for antiretroviral therapy (ART) for HIV are intended to increase patient-centeredness, a concept that incorporates patient choice of service delivery options. We explored choice in DSD model enrollment at 42 public sector clinics in Malawi, South Africa, and Zambia.

Methods

From 09/2022-05/2023, we surveyed ART clients and healthcare providers, asking ART clients if they had a choice about DSD model enrollment and providers about their practices in offering choice. We estimated risk differences for ART clients’ self-reported offer of choice using a Poisson distribution with an identity link function and report risk differences. We thematically analyzed open-ended questions and report key themes.

Results

We enrolled 1049 clients (Malawi 409, South Africa 362, Zambia 278) and 404 providers (Malawi 110, South Africa 175, Zambia 119). The proportion of clients indicating that they had been offered a choice ranged from 4% in Malawi to 17% in Zambia to 47% in South Africa. Few clients (Malawi 10%, South Africa 19%, Zambia 13%) reported they had actively asked to enroll in a DSD model, but a majority (Malawi 66%, South Africa 80%, Zambia 59%) indicated they consented to model enrollment, even if enrollment was not presented as a choice. Over 90% of clients in all three countries reported that they were happy to be enrolled in their current DSD model. Among providers, 64% in Malawi, 80% in South Africa, and 59% in Zambia said they offered clients the choice to enroll in DSD or remain in conventional care.

Conclusions

As of 2023, relatively few ART clients in Malawi, South Africa, and Zambia said they were offered a choice about enrolling in a differentiated service delivery model, despite most providers reporting offering a choice. The value of patient choice in improving clinical outcomes and satisfaction should be explored further.

Plain-Language Summary

Purpose

Differentiated service delivery (DSD) models for antiretroviral therapy (ART) enhance patient-centeredness by offering choices in service delivery options. We explored choice in DSD model enrollment at 42 public sector clinics in Malawi, South Africa, and Zambia.

Methods

From 09/2022-05/2023, we surveyed ART clients and healthcare providers, asking clients whether they had a choice about DSD model enrollment and providers whether they offered this choice to their clients. We analyzed the data to identify differences in how clients reported being offered a choice.

Results

1,049 clients participated: 409 from Malawi, 362 from South Africa, and 278 from Zambia, alongside 404 providers (110 in Malawi, 175 in South Africa, and 119 in Zambia). 4% of clients in Malawi, 17% in Zambia, and 47% in South Africa reported being offered a choice to enroll in a DSD model. Few actively sought to join a DSD mode (Malawi 10%, South Africa 19%, and Zambia 13%)—but many consented to enroll even when not explicitly offered (Malawi 66%, South Africa 80%, Zambia 59%). Over 90% of all clients were happy with their current DSD model. Among providers, 64% in Malawi, 80% in South Africa, and 59% in Zambia offered clients the choice to enrol in a DSD model or remain in conventional care.

Conclusions

Most ART clients in our study did not report being offered a choice to join a DSD model despite providers claiming they offered one. Further research is needed to understand how offering choices could improve health outcomes and patient satisfaction with care.