Implementing WHO Differentiated Service Delivery Model for Pregnant and Breastfeeding Women and Infants Living with HIV: Insights from Kenyan Healthcare Providers

Abstract

Background and Objective:: Differentiated service delivery (DSD) is a strategy endorsed by the World Health Organization that simplifies and adapts human immunodeficiency (HIV) services to meet the needs of people living with HIV (PLHIV) while reducing unnecessary health system burdens. DSD for PLHIV has been widely adopted in sub-Saharan Africa, but DSD for women and infants enrolled in prevention of mother-to-child HIV transmission (PMTCT) services is lacking.

Methods:: We conducted in-depth interviews with healthcare providers (i.e., clinicians, nurses, and mentor mothers) in antenatal and postnatal clinics at two facilities affiliated with the Academic Model Providing Access to Healthcare (AMPATH) in Kenya to explore perspectives on the adaptation of DSD for PMTCT. Providers were recruited in person at each facility. Interview guides focused on their views on DSD implementation for PMTCT, characteristics of stable and unstable PMTCT clients, and strategies to improve PMTCT services. We used inductive coding with illustrative quotes to highlight emerging themes.

Results:: 12 PMTCT providers (6 antenatal, 6 postnatal; 4 clinicians, 4 nurses, and 4 mentor mothers) were enrolled; 10 (83%) were female, with a median age of 40 years, and a median of 7 years of PMTCT experience. Providers held positive views about the potential benefits of DSD for PMTCT but expressed concern about reducing service intensity during pregnancy/breastfeeding. Providers also suggested specific criteria defining stable PMTCT clients beyond those used for non-pregnant PLHIV, such as having no pregnancy complications, psychosocial or socioeconomic barriers, or breastfed infants.

Conclusion and Global Health Implications:: Filling the gap in DSD guidance for this population will require adaptations to the DSD model that are responsive to providers’ concerns and the unique aspects of the pregnancy-postpartum service continuum, which may vary across settings based on contextual and client-level factors. Such nuanced guidance will need to remain clear and simple to implement to ensure implementation fidelity at scale.

Figure 1. Conceptual framework describing the factors influencing DSD implementation. This figure outlines a user-centered approach to delivering PMTCT services, guided by the WHO building blocks for DSD (when, where, who, what) and influenced (positively or negatively) by various factors at the levels of the contextual environment and PMTCT clinic. PMTCT: Prevention of mother-to-child HIV transmission, DSD: Differentiated service delivery, MCH: Maternal-child health, ART: Antiretroviral therapy