Abstract
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Abstract; Background Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)’s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perceptions of the early implementation experiences of national DSD roll-out across Uganda. Methods We utilized a qualitative research design involving 124 participants. Between April and June 2019 we conducted 76 semi-structured interviews with national-level HIV program managers (n=18), District Health Team leaders (n=24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by the multi-level analytical framework by Levesque et al. (2013): Individual-level factors; Health-system factors; Community factors; and Context. Results Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level factors: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system factors: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community factors: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Contextual factors: Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating drug pick-ups. Conclusion This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing self-stigma barriers, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).