Policies on HIV Treatment Delivery Are Lagging Behind the Latest Science

The World Health Organization and major donors such as PEPFAR and The Global Fund have endorsed innovative HIV service approaches known as differentiated service delivery. These practices could ease the burden of treatment on patients, improving adherence to antiretroviral treatment and viral suppression globally. They could also provide savings in millions of dollars to health systems. But sub-Saharan Africa is not yet seeing all of these benefits because parts of the region lag behind uptake of evidence on differentiated HIV care delivery.

Traditional HIV service delivery is a one-size-fits-all model that requires fixed monthly visits to clinics for physician-intensive and facility-based care for all patients with HIV regardless of their clinical need. In contrast, differentiated HIV care is tailored to the needs of individual patients and can provide equal or better outcomes, as shown in Malawi, South Africa, and Uganda. For stable patients—who comprise the majority of people living with HIV across the globe—differentiated service delivery reduces clinic visits and, consequently, saves on the cost of transportion and time off work. For health workers, it promises to reduce workloads and ensure that patients with the highest clinical need receive the attention they deserve.

Policymaking is the starting point for implementing innovations in HIV service delivery. Studies demonstrate that having the right HIV policies in place results in tangible benefits such as increased HIV treatment coverage. But a new global report reveals that the majority of countries across the world have not revised their national policies to align with the latest science on differentiated HIV treatment services.

HIV Policy Lab’s 2022 global report reveals that only 13% of countries have policies providing for the three significant models of differentiated HIV care: 1) decentralization of drug distribution to the community; 2) reduction in the frequency of clinic visits for stable patients; and 3) provision of a three- to six-month supply of HIV medication. While few countries provide all three models of care, 60% of countries worldwide provide for at least one model.

Countries in Eastern and Southern Africa have more than double (43%) the rate of policy adoption of all three models of differentiated HIV care than any other region in the world. Western and Central Africa follow with a 23% adoption rate, and Asia and the Pacific at 10%. Countries supported by PEPFAR have closer policy alignment with differentiated HIV treatment services compared with non-PEPFAR-supported countries, which indicates the importance of internal and external actors in driving HIV policy change.

The HIV Policy Lab report shows that policy adoption of differentiated HIV care accelerated in 2020 and 2021 across the globe, including in low-burden countries such as the Unites States. This acceleration was likely due to COVID-19 travel restrictions, which rendered community-based drug distribution a lifeline for people living with HIV. Overall, policy uptake appeared to be higher in regions with a high HIV burden. Eastern and Southern Africa are a part of the world most affected by HIV, accounting for 45% of all HIV infections worldwide and home to 53% of all people in the world living with HIV.

Yet the unmet need for HIV treatment remains high. Across sub-Saharan Africa, and particularly in Western and Central Africa, only 21% of children with HIV are accessing treatment—the lowest treatment coverage of children in the world. Sub-Saharan African countries’ implementation of the “test and treat” approach to HIV since 2016—under which all people diagnosed as HIV positive were to be placed on antiretroviral treatment regardless of clinical stage—dramatically increased the number of people in need of HIV treatment in the region and globally. Related in part to this policy change, it is common to find that HIV clinics across sub-Saharan Africa are heavily congested and waiting times for patients are unbearably long. Health workers often endure heavy workloads with no respite in the endless patient queues.

To meet the increased demand for care, we need to accelerate reforms to national policies, particularly in areas where the need is greatest, such as Western and Central Africa, to align them with the latest HIV science.

It is imperative that countries in Western and Central Africa—and across the world—reform their national treatment guidelines to align with the latest evidence on differentiated HIV care. Identifying local champions, civil society advocates, and external assistance in domesticating the latest science in HIV treatment delivery in national policies will be critical to achieving global HIV epidemic control by 2030.

Henry Zakumumpa is a senior research fellow at Makerere University in Uganda. He recently participated in a PRB policy communication program that focuses on strengthening the capacity of early-career researchers working on population and health studies to engage policy influencers and decisionmakers effectively.