BACKGROUND: Differentiated service delivery has potential for improved service delivery and health outcomes through tailored services that reduce overall costs to providers and people living with HIV. We examined patient and provider experiences of one model, Urban Adherence Groups (UAGs), to distil lessons regarding supply- and demand-side acceptability and feasibility in Zambia.
METHODS: Nested within a matched-pair cluster-randomized effectiveness trial of UAGs in Zambia, we conducted endline focus group discussions with study-enrolled patients (32), professional (16) and lay (16) healthcare workers (HCW); and interviews with 32 study staff, 10 clinic in-charges and 9 provincial or district health directors. Inductive and deductive analysis was used to synthesize findings under the themes 'acceptability' (general perceptions about, or experiences with UAGs) 'appropriateness' (assessment of clinical or psycho-social impact); and 'feasibility' (qualitative evaluation of resources and capabilities required scale-up and sustain UAGs long-term).
RESULTS: Patients and HCW found UAGs to be highly acceptable, with reduced queuing and congestion a key theme. For patients, reduced congestion freed time to meet livelihood needs and lessened concerns about unintentional disclosure from attending public clinics. Routine access to information and meaningful group support also reduced self-stigma. Patients described UAGs as appropriate due to improved accessibility of medication, a preference for group (versus one-on-one) counselling and the 'opportunity to interact with the [UAG-specific] staff' without fear of being 'shouted at'. Group size and mixed gender groups were generally viewed as appropriate. HCW, however, expressed concerns about UAG appropriateness due to reduced frequency of clinical checks. Patients and HCW both viewed the UAG model as feasible, contingent on staff and funding inputs. Two preconditions for scaling-up UAGs were commonly mentioned. First, professional HCWs appointed to lead UAGs should be selected for and trained to deliver 'friendly' 'helpful' and efficient care. Second, establishment of formal MOH employment for lay (or community) health care workers was needed, recognising their key linkage, navigation and education roles in UAG success.
CONCLUSIONS: UAGs demonstrate promise as a one mechanism for improving patient experience of, and engagement in HIV treatment in Zambia, but require adequate human resourcing and oversight.