Eswatini's Differentiated Service Delivery (DSD) models: adaptation, scale-up and monitoring

BACKGROUND: Since 2016, the Eswatini Ministry of Health (MOH) has prioritized the expansion of HIV differentiated service delivery (DSD), including scale-up of differentiated treatment (DT) models. Because routine monitoring and evaluation (M&E) systems did not capture key DT data, MOH invested in adaptations to the national electronic Client Management Information System (CMIS) to enable tracking of DSD-relevant data, collected ad hoc data on DT scale-up, and conducted annual DSD system self-assessments supported by the multi-country CQUIN learning network.
DESCRIPTION: We triangulated scale-up of DT in Eswatini using national HIV annual program reports (2016-2020), CMIS quarterly reports (2020-2021), results from DT client satisfaction study, and Eswatini's CQUIN annual meeting reports and capability maturity model dashboard staging (2018-2021).
LESSONS LEARNED: The proportion of health facilities (HF) implementing DT grew from 22/176 (29%) in 2016 to 193/202 (96%) in 2020. The proportion of ART clients enrolled in DT rose from 13,791/174,103 (7.9%) in 2017 to 164,336/204,286 (80.4%) in 2020. The diversity of DT models also increased over time; the eight current models include 5 facility-based, (Mainstream, Fast Track, Family Centered Care, Treatment Clubs, Teen Clubs) and 3 community-based models (Outreach, Community Drug Distribution, and Community Antiretroviral Therapy (ART) groups). Tailored DT models are available for adults, adolescents, people with HIV and co-morbidities, advanced HIV disease, men, pregnant and breast-feeding women, high viremic, and key and vulnerable populations. All DT models offer 3-multimonth dispensing (MMD) or 6MMD. Ad hoc studies indicate high levels of client satisfaction. National systems cannot yet compare viral load suppression (VLS) for clients in different models, but VLS for all PLHIV on ART increased from 90% (males) and 91% (females) in 2017 to 96% and 97% respectively in 2020.
CONCLUSIONS: Eswatini has markedly scaled up DT coverage and diversity, ensuring that HIV treatment is responsive to the needs of different groups and sub-populations. An increasing proportion of PLHIV are virally suppressed, receiving their HIV treatment through DSD models with extended ART refills and less frequent clinical visits. Moving forward, ongoing investments in CMIS will allow MOH to use routine program data for in-depth monitoring of DT model uptake and outcomes.

Download the e-Poster (PDF)