Differentiated Services Delivery Model Uptake and Outcomes in Uganda: Gaps, Facilitators, and Barriers - A Mixed Methods Study 2019–2021

Background Differentiated service delivery (DSD) models have emerged as innovative approaches to optimize HIV service delivery, particularly in bridging gaps across the HIV test–treat–care cascade. We assessed the performance of DSD models in Uganda, focusing on enrollment, retention in care, viral load (VL) testing, and suppression, while identifying key challenges and facilitators of effective implementation. Methods We conducted a retrospective review of records for closed cohorts of people living with HIV (PLHIV) active in care from 2019--2021 across health facilities supported by the Makerere University Joint AIDS Program (MJAP) and Mildmay Uganda. We determined the proportion of PLHIV who were active in care, enrolled in a DSD model, completed a VL test, and achieved suppression. Additionally, we conducted key informant interviews and focus group discussions to explore stakeholder perspectives on implementation challenges and facilitators. Results Among the 1,141 PLHIV, 530 (2019), 432 (2020), and 393 (2021) were active in care. DSD model enrollment increased from 48% in 2019 to 90% in 2021. The fast-track drug refill (FTDR) model had the highest uptake, increasing from 31% to 72%, whereas the facility-based individual management (FBIM) model declined from 55% to 10%. Viral load testing coverage improved from 73% to 85%, with suppression rates rising from 86% to 96% over the study period. Qualitative data revealed key facilitators, including reduced patient costs, improved provider–patient engagement, and partner support. Barriers included stigma, medical stockouts, patient relocation, and limited service integration in community-based models. Discussion This mixed-methods study analyzed three years of differentiated service delivery (DSD) for Ugandan PLHIV, tracking enrollment, viral load testing, and suppression and interviewing stakeholders. Enrollment and suppression improved the most in facility-based fast-track drug refill, facilitated by training, mentorship, and partner support. Stockouts, stigma, and unstable patients address hindered progress. Strengthening community models and integrating comorbidity care remain key. Conclusion The uptake and quality of DSD models improved over time, with a strong preference for the FTDR model. However, addressing persistent barriers, especially stigma, service integration, and resource availability, is essential to achieve sustained scale-up and improved HIV care outcomes in Uganda.