DIFFERENTIATED HIV

SERVICE DELIVERY (DSDM)

Learning Objectives

 Describe common modalities for differentiated

service based on the client’s need.

 Describe the patient classification model for

differentiated service delivery models,

 Describe the criteria for implementation of

DSD model,
Definition of DSD
Differentiated service delivery, or
 Differentiated care is a client-centered approach that
simplifies and adapts HIV services across the cascade
to reflect the preferences and expectations of groups of
people living with HIV (PLHIV) while reducing
unnecessary burdens on the health system.
 Test and Start increase patients on ART which is
already overburdened.
 Differentiated model of care create: longer intervals of
clinical presentation and refill & community-based
delivery of ART.
 DSD: meet clients need, decongesting overburdened ART
site, meet diversity of patients needs and program
expansion.
New Recommendations on DSD
• In the previous guidance Differentiated service delivery
for HIV treatment has focused primarily on people who
are clinically stable (established on ART).
• The need has been recognized to adapt services for
those with AHD, HVL, and comorbidities through
simplified care packages and differentiated models of
service delivery;
• Principles of differentiating service delivery is
improving uptake of HIV testing and prevention
• Differentiated service delivery for HIV treatment is based
on four building blocks
DSD Building Blocks
DSD Four Building Block
• Building block need to define: clinical
consultation, ART refills and psychosocial
support.
• 1st differentiated HIV service delivery in 2017 is
Appointment Spacing Model/6MMD, Fast Track
ART Refill, 3MMD, HEP, CAGs, PCAD, and
Adolescent ART group, AHD, MCH and Key
population.
• DSD applies in HIV continuum of three 95’s;
• DSD model is based in facility or community.
Classification of DSD model
1.Less intensive DSD models: This individual and
group model is intended for clients who are
established on ART.
• It includes both facility and community-based
approaches.
• It requires less frequent clinic visits and focuses on
the education and empowerment of clients.
2. More intensive DSD models: This Model is
intended for clients who need close follow-up and
frequent clinic visits.
• It includes clients with OI, unsuppressed viral load
adolescents, pregnant women, and those with
psychosocial barriers to adhering and retention.
Eligibility criteria for less intensive DSD model

• Patients who are on ART for at least six months

• No current illness, which does not include well-
controlled chronic health conditions
• Good understanding of lifelong adherence;
• Evidence of treatment success (at least one suppressed
viral load result (i.e < 50 c/ml) and if no Viral Load result,
a patient with rising CD4 cell count or CD4 cell count
above 200 cells/millimeter cubes).
Eligibility criteria for less intensive DSD model
cont…

• Children with age >five years

• A Patient who doesn’t have current OIs
• A Patient with no adverse drug reactions and doesn’t
need careful clinical monitoring.
• A Patient who is willing or provides consent to get the
ART service based on his/her preferred DSD models.
Differentiate
d service
delivery
(DSD)
framework in
Ethiopia
1. Appointment Spacing Model(ASM/6MMD)
• Stabile clients will be appointed very six months:
clinical and refill;
• Additional support with treatment supporter at
home- family members and adherence reminder
use alarm and education.
• Counsel and Encourage to disclose status and
participate in peer group; and
• Disclosed clients can be adherence support via
home visit or telephone follow-up.
2. Three Months ARV Dispensing(3MMD)
• Clients not willing to enrolled in appointment
Spacing will be appointed every three months;
• For children 3MMD- care giver allowed to pick
the child’s medication without bringing child;
• Fro clients who use CPT 3-6months supply can
provided by multi-month intervals at the same;
and
• Use virtual follow-up using phone call and other
communication technique.
3. Fast Track ARV Drugs Refill Model
• Facility based DSD Models of HIV care where
clients are stable and make clinical visit once
every 6 months but collect medication
every 3 months;
• It can provide opportunity for ASM- for clients
who faced difficulty to take 6 months to their
homes at once from pharmacy.
4. Health Extension Professional Managed
Community ART Refill Group(HEP-CAG)
• For groups of stable clients on ART living in the community;
• Health extension professionals(HEP) can manage it;
• ART refill for 3 months and each CAG have one community
refill and health facility visit happen every 6 months and
clients can be referred at any time;
• Health professionals will find clients I the same group and
link to HEP;
• Each CAG will have 6 individual member and place will be
selected the refill site;
• Pharmacist will identify clients for Community-based and
prepackage. Label of ARVs and OI drugs; and
• HEP will collect pre-packed/pre-labeled medication and
assess adherence assessment, counseling, Side effect
5. Peer lead Community Based ART
Distribution/Group(PCAD/G)
• Comprise stable clients living in the same community.
• PCAD group member will take turns to pick-up ARVs at
health facility and distribute among group members;
• Each individual get clinical evaluation and lab monitoring
service every six months as package;
• Group member collaborate with healthcare workers with
selected group members;
• Peer leader will conduct adherence assessment and monitor
events;
• Each PCAD will have six individual member and select place
of refill at community; and
• ART pharmacist receive list of member and pre-packing or
labeling of ARVs and OIs drugs prior to refill and responsible
peers will collect on the date
More Intensive Model:

• This Model is intended for clients who need close

follow-up and frequent clinic visits.
• It includes clients with OI, unsuppressed viral load
adolescents, pregnant women, and those with
psychosocial barriers to adhering and retention
1. DSD Model for adolescent living with HIV
(DSD for ALHIV
• DSD Adolescent has 3 core element: ART refill, Clinical
consultation and psychosocial support;
• Young pass psychosocial support & facilitate voluntarily;
Eligibility for adolescent DSD:
• Adolescent clients who disclosed their HIV status and are
willing or provide consent to get the ART service based on/or
their preferred DSD models.
• Health care facility where there is a functional pediatric
psychosocial support program,
• Adolescents aged10- 19 years, fully disclosed, enrolled in the
pediatric psychosocial support program,
• No restriction on stability- including both with the suppressed
and unsuppressed viral load test result
2. DSD for key populations (for FSWs)
• There are efforts to make public and private facilities
KP friendly by building the capacity of providers
and arranging service delivery approaches to match
their needs.
• Confidentiality clinics and drop-in centers (DICs)
were established around hot spot areas that provide
comprehensive HIV services to female sex workers.
• The KP-friendly services delivered at drop-in centers
have significantly improved HIV prevention, care, and
treatment service access to FSWs.
3. MCH _DSD
• Mothers living with HIV and their infants are an
important target population for the differentiated
service model (DSD).
• There are various models of care used to support
MCH/HIV services.
• Some of the DSD models in Ethiopia include family
planning service integration to HIV care, point of
care (POC) EID(early infant Dx) testing for HEIs
• Provision of 3-month ARV dispensing for HIV-
positive pregnant and breastfeeding women during
the COVID 19 pandemic.
4. DSD for Advanced HIV Disease and PLHIV at
high-risk Disease Progression
• For adults and adolescents, and children older than
five years, advanced HIV disease is defined as: CD4
cell count <200 cells/mm3 or ‘WHO stage 3 or stage 4
event’.
• All children under 5 who are not on effective ART are
considered to have the advanced disease because of
high viremia and rapid disease progression with
high mortality.
• For patients with advanced HIV disease, the frequency
of clinical visits is recommended every month.
Section Summary
 For ART is a lifelong treatment for HIV,
clients need a differentiated service that
fits their routine life,
 Based on the level of stability of the
clients, DSD models can be based in the
facility or in the community
 The classification of DSD models includes
less intensive and more intensive models