Changes in HIV treatment differentiated care uptake during the COVID‐19 pandemic in Zambia: interrupted time series analysis

  1. Youngji Jo
  2. Sydney Rosen
  3. Karla Therese L. Sy
  4. Bevis Phiri
  5. Amy N. Huber
  6. Muya Mwansa
  7. Hilda Shakwelele
  8. Prudence Haimbe
  9. Mpande M. Mwenechanya
  10. Priscilla Lumano‐Mulenga
  11. Brooke E. Nichols

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Abstract

Introduction

Differentiated service delivery (DSD) models aim to improve the access of human immunodeficiency virus treatment on clients and reduce requirements for facility visits by extending dispensing intervals. With the advent of the COVID‐19 pandemic, minimising client contact with healthcare facilities and other clients, while maintaining treatment continuity and avoiding loss to care, has become more urgent, resulting in efforts to increase DSD uptake. We assessed the extent to which DSD coverage and antiretroviral treatment (ART) dispensing intervals have changed during the COVID‐19 pandemic in Zambia.

Methods

We used client data from Zambia's electronic medical record system (SmartCare) for 737 health facilities, representing about three‐fourths of all ART clients nationally. We compared the numbers and proportional distributions of clients enrolled in DSD models in the 6 months before and 6 months after the first case of COVID‐19 was diagnosed in Zambia in March 2020. Segmented linear regression was used to determine whether the outbreak of COVID‐19 in Zambia further accelerated the increase in DSD scale‐up.

Results and discussion

Between September 2019 and August 2020, 181,317 clients aged 15 or older (81,520 and 99,797 from 1 September 2019 to 1 March 2020 and from 1 March to 31 August 2020, respectively) enrolled in DSD models in Zambia. Overall participation in all DSD models increased over the study period, but uptake varied by model. The rate of acceleration increased in the second period for home ART delivery (152%), 2‐month fast‐track (143%) and 3‐month MMD (139%). There was a significant reduction in the enrolment rates for 4‐ to 6‐month fast‐track (−28%) and “other“ models (−19%).

Conclusions

Participation in DSD models for stable ART clients in Zambia increased after the advent of COVID‐19, but dispensing intervals diminished. Eliminating obstacles to longer dispensing intervals, including those related to supply chain management, should be prioritized to achieve the expected benefits of DSD models and minimize COVID‐19 risk.

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  1. Version published to 10.1002/jia2.25808
  2. ScreenIT

    SciScore for 10.1101/2021.03.20.21254021: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    . (The R Project for Statistical Computing, Vienna Austria).
    R Project for Statistical
    suggested: (R Project for Statistical Computing, RRID:SCR_001905)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study has several limitations. We relied entirely on routinely collected medical record data, which may be incomplete in some cases. While interrupted time series analysis allows the ability to control for secular trends in the data (unlike pre-/post-cross-sectional studies) using population-level data with clear graphical presentation of results, this analysis does not illustrate how and why the introduction of COVID-19 resulted different scale-up patterns by DSD models and whether and to what extent the temporal changes may differ by setting. Future research may examine the drivers and barriers of multi-month dispensing from both the demand and supply side aspects in the context of COVID-19 to improve continuation of care. Moreover, this analysis focused on DSD enrolment only; we have not considered retention in the DSD models or care more generally. Future work should aim to understand how this rapid acceleration of DSD uptake has affected overall retention in care.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  3. Version published to 10.1101/2021.03.20.21254021v1 on medRxiv