HIV service delivery
HIV service delivery includes a comprehensive package of HIV testing, prevention, treatment and care services provided for people at risk of acquiring HIV, people living with HIV (PLHIV) and their partners, and families and caregivers. HIV service delivery should provide people-centred care that is focused on people’s health needs, preferences, and expectations, upholding dignity and respect, especially for vulnerable populations. Engaging and supporting individuals and their families is critical, so that people can make informed decisions and play an active role in their own care.
Examples of HIV services include:
- HIV prevention, such as PrEP;
- HIV testing (including HIV self-testing) and linkage to enrollment in care;
- managing opportunistic infections and other comorbid conditions, integration of other services, task sharing and decentralization;
- initiating, maintaining and monitoring antiretroviral therapy (ART);
- psychosocial, adherence, retention and re-engagement support;
- switching to second-line and third-line ART;
- home based and palliative care; and
- facility and community differentiated ART delivery models, frequency of clinic visits and medication pickup.
Rapid scale-up of ART continues to require adaptations in the way that HIV/AIDS services are delivered. Differentiated approaches to service delivery are recommended to increase access to and retention on ART treatment – the approach will vary according to the service needs of each patient.
WHO guideline on HIV service delivery
Supporting re-engagement in HIV treatment services
Quality of HIV services
HIV service delivery also includes recommendations for quality HIV services and health systems strengthening. Quality HIV services include the reliable delivery of clinical care across diverse community and facility settings that are people-centred and integrated with other services at the national, subnational, district and facility levels. Delivery of quality services depends on the quality and strength of all health systems’ building blocks – this includes optimized management, funding, human resources for health, information systems, and procurement of high-quality drugs, laboratory supplies and commodities. Health systems strengthening also includes the implementation of tools for patient monitoring, referral and back-referral, clinical team capacity-building and mentoring.
Adherence and retention
Adherence to and retention on ART are primary determinants of viral suppression and the risk of transmission, disease progression, and death.
Adherence is the extent to which a person’s behaviour – taking medication, attending scheduled clinic appointments, following a diet and/or changing lifestyle – corresponds with care and treatment plans conjointly agreed between the health worker and the person living with HIV. Retention in HIV care means the person enrolled in HIV care routinely attends these services in accordance with their needs. |
Suboptimal adherence is a significant challenge worldwide. It is associated with a diversity of individual and health system-related barriers, and can lead to patient disengagement from care and treatment. Individual factors are related to physical, psychological, behavioural and social-economic challenges. Infants and young children, adolescents and young people, pregnant and postpartum women, men and key populations all face specific adherence and retention challenges at different stages of their progression.
WHO recommends a set of facility- and community-level interventions to provide support with psychosocial, adherence, retention and re-engagement issues, as well as treatment monitoring. These interventions have demonstrated benefit in improving adherence and viral suppression.
Psychosocial support addresses the ongoing psychological and social barriers faced by PLHIV, their partners, families and caregivers. It includes:
- referral and provision of psychological services for assessment, management and treatment of depression and substance use disorders, regardless of HIV status;
- the referral and access to existing socio-economic services;
- enrollment on differentiated models of ART delivery, and
- community and peer support to motivate PLHIV to better cope with adherence barriers, engage in new social networks and deal more effectively with discrimination.
Adherence support includes peer counsellors, supporters or navigators; mobile phone text messages; reminder devices; cognitive-behavioural therapy; behavioural skills training and medication adherence training; and fixed-dose combinations and once-daily regimens.
Retention support refers to task sharing, decentralization of care and differentiated service delivery. This includes providing a package of community-based interventions and less frequent clinic visits and medication dispensing, as well as extra care for people with advanced HIV disease.
Peer supporters and patient advocates can provide community-level adherence and psychosocial support interventions, such as adherence clubs and intensive/enhanced adherence counselling, and home-based/palliative care for high-risk people.
Re-engagement support refers to the key role played by peer supporters/navigators and counsellors in welcoming and supporting ART clients’ who have interrupted treatment, by re-engaging them through remote communication (e.g. phone, text, mail and email), in-person tracing, or a combination of both approaches.
Viral load for treatment monitoring should be complemented with non-judgmental, tailored, simple and affordable approaches to assessing adherence (e.g. pill counts, pharmacy refill records and self-reporting). This should be viewed as an opportunity to discuss treatment issues with patients, and to identify and address potential barriers to maintaining adequate adherence.