Impact of differentiated service delivery models on retention in HIV care and viral suppression among people living with HIV in sub-Saharan Africa: A systematic review and meta-analysis of randomised controlled trials

Abstract

Differentiated service delivery (DSD) models, such as adherence clubs (ACs), are client-centred approaches where clinically stable people living with HIV (PLHIV) meet to receive various services, including psychosocial support, brief symptoms screening, and refills of antiretroviral medications, among others. We conducted a review to assess the impact of DSD models, including ACs, on sustaining retention in care (RC) and achieving viral suppression (VS) among PLHIV in sub-Saharan Africa. The review protocol was registered in PROSPERO (CRD42023418988). We searched the literature from PubMed, Scopus, Web of Science, Embase and Google Scholar from their inception through May 2023. Eligible randomised controlled trials of adherence clubs were reviewed to assess impact on retention and viral suppression. Random effect models were used to estimate the risk ratios (RR) and 95% confidence intervals (CI). The literature search yielded a total of 1596 records of which 16 randomised clinical trials were determined to be eligible. The trials were conducted in diverse populations among adults and children with a total of 13,886 participants. The RR between any DSD models and standard of care (SoC) was 1.09 (95% CI: 1.08-1.11, I² : 0%, p: <0.96) and 1.01 (95% CI: 1.00-1.02, I² : 0%, p: <0.85) for RC and VS, respectively. The RR between ACs and SoC was 1.01 (95% CI: 0.96-1.07, I² : 84%, p: <0.01) and 1.02 (95% CI: 0.98-1.07, I² : 77%, p: <0.01) for RC and VS, respectively. DSD models, including ACs, show comparable effectiveness to SoC in maintaining care and achieving viral suppression for stable PLHIV. To maximise adoption, an implementation science approach is crucial for designing effective strategies and overcoming challenges.

Keywords: adherence clubs; adherence to antiretroviral treatment; retention in HIV care; sub-Saharan Africa; viral suppression.

FIGURE 1

PRISMA flow chart, describing the process involved in study screening.

FIGURE 2

Risk of bias assessed using version 2 of the Cochrane risk-of-bias tool for randomised trial.

FIGURE 3

Meta-analysis of any type of differentiated service delivery model as an intervention when compared to any type of standard of care as a control. Retention was determined 12 months from the baseline while viral suppression was defined as any viral load below 1000 copies/mL taken any time above 6 months from the baseline.

FIGURE 4

Meta-analysis of any type of adherence club model as an intervention when compared to any type of standard of care as a control. Retention was determined 12 months from the baseline while viral suppression was defined as any viral load below 1000 copies/mL taken any time above 6 months from the baseline.