Impact of differentiated service delivery models on quality of life among people living with HIV in Uganda- a quasi-experimental study

Abstract

Background: Differentiated service delivery (DSD) models in resource-limited settings reduce strain on health services and improve clinical outcomes such as retention and viral suppression, but little is known about the impact of HIV DSD models on quality of life (QoL), which is essential for optimizing person-centered care. This study assessed the impact of DSD models on Quality of life, loss to follow-up (LTFU), and mortality among persons living with HIV (PLHIV) on Antiretroviral therapy (ART) over time at a large urban HIV clinic in Uganda.

Methods: Records of 1,000 PLHIV enrolled in a 10-year cohort at the Infectious Diseases Institute (IDI) clinic in Kampala, Uganda were retrospectively analyzed. QoL was assessed using an adapted Medical Outcomes Study (MOS-HIV) tool. QoL scores, sustained annual viral suppression (< 200 copies/mL), all-cause mortality and LTFU (≥ 3 months of missed visits) were compared for PLHIV in three DSD models for ≥ 6 consecutive months-fast-track drug refill (FTDR), facility-based groups (FBG), and composite model combining these two-versus facility-based individual management (FBIM) or the standard of care (SOC). Inverse probability treatment weighting was applied for covariate comparability while robustness of results was checked using G-computation. Sustained viral suppression was compared using odds ratios; all-cause mortality and LTFU were compared using hazard ratios from the Cox proportional hazard regression model.

Results: Of the 1,000 PLHIV, 980 had ≥ 1 follow-up and were included in the analysis. Median age was 45 years (IQR: 40-51), 62% were female, and 95% had a suppressed viral load at baseline. Baseline QoL was 90.1% in any DSD model vs. 89.2% in SOC. After eight years of follow-up, weighted mean QoL was higher in participants enrolled in DSD models than the SOC (90.4% vs. 89.1%; weighted mean ratio 3.66, 95% CI 2.10-6.37, p-value < 0.001); there were no statistical differences across DSD models. Participants in DSD models were more likely to have sustained viral suppression (weighted odds ratio 1.69, 95% CI 1.24-2.31), lower mortality (weighted hazard ratio 0.08, 95% CI 0.03-0.20) and lower LTFU rates (weighted hazard ratio 0.08, 95% CI 0.02-0.31).

Conclusion: DSD models were associated with modestly higher quality of life, better viral suppression, and lower mortality and LTFU compared to the standard of care. These findings support the broader adoption of DSD models in delivering ART across HIV programs to enhance the QoL and clinical outcomes among PLHIV.

Keywords: Antiretroviral therapy; Delivery of health care; HIV infections; Health services accessibility; Quality of life.

Fig. 1

Mean QoL score over time by any DSD model Vs SOC Quality of Life scores are at 100-percentage points scale. The Y-axis is truncated at 70% for clear visibility of the difference between groups

Fig. 2

Mean QoL score profile over time by different DSD model categories Quality of Life scores are at 100-percentage points scale. The Y-axis is truncated at 70% for clear visibility of the difference between groups. The dashed black vertical line denotes the second wave 2021 COVID-19 lockdown in Uganda

Fig. 3

IPTW weighted estimates for outcomes by any DSD vs. SOC IPTW = Inverse Probability Treatment Weighting SOC = Standard of care VLS = Viral load suppression wOR = weighted Odds Ratio, wHR = weighted Hazard Ratio, wMR = weighted Mean Ratio