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. 2025 Jun 25:19:1825-1841.
doi: 10.2147/PPA.S494679. eCollection 2025.

Are HIV Treatment Clients Offered a Choice of Differentiated Service Delivery Models? Evidence from Malawi, South Africa, and Zambia

Idah Mokhele  1 , Vinolia Ntjikelane  1 , Nancy A Scott  2 , Jeanette L Kaiser  2 , Allison Juntunen Morgan  2 , Amy Huber  1 , Nomcebo Oratile Mokgethi  1 , Timothy Henry Tchereni  3 , Wyness Phiri  3 , Aniset Kamanga  4 , Prudence Michelo Haimbe  4 , Priscilla Lumano-Mulenga  5 , Rose Kolola Nyirenda  6 , Sophie J S Pascoe  1 , Sydney Rosen  1   2
Affiliations

Are HIV Treatment Clients Offered a Choice of Differentiated Service Delivery Models? Evidence from Malawi, South Africa, and Zambia

Idah Mokhele et al. Patient Prefer Adherence. .

Abstract

Purpose: Differentiated service delivery (DSD) models for antiretroviral therapy (ART) for HIV aim to increase patient-centeredness, a concept that incorporates patient choice of service delivery options. We explored choice in DSD model enrollment at 42 public sector clinics in Malawi, South Africa, and Zambia.

Methods: From 09/2022-05/2023, we surveyed people receiving HIV treatment to ask if they had a choice about DSD model enrollment and healthcare providers about their practices in offering choice. We estimated risk differences for ART clients' self-reported offer of choice and report risk differences. We thematically analyzed open-ended questions and report key themes.

Results: We enrolled 1049 people receiving HIV treatment (Malawi 409, South Africa 362, Zambia 278) and 404 providers (Malawi 110, South Africa 175, Zambia 119). The proportion of study participants indicating that they had been offered a choice ranged from 4% in Malawi to 17% in Zambia to 47% in South Africa. Over 90% of people receiving HIV treatment in all three countries reported that they were happy to be enrolled in their current DSD model. Participants from urban (ARD 0.94 [0.90-0.99]) and medium-volume facilities (2000-4000 ART clients, 0.91 [0.84-0.98]) were slightly less likely to be offered DSD enrollment. Participants in community-based models 1.21 [1.12-1.30] and those satisfied with their current model 1.06 [1.01-1.13] were more likely to be offered a choice. Among providers, 64% in Malawi, 80% in South Africa, and 59% in Zambia said they offered clients the choice to enroll in DSD or remain in conventional care.

Conclusion: As of 2023, relatively few people receiving HIV treatment in Malawi, South Africa, and Zambia reported being offered a choice about enrolling in a DSD model, despite most providers reporting offering such a choice. The value of patient choice in improving clinical outcomes and satisfaction should be explored further.

Keywords: antiretroviral therapy; client choice; client-centered; differentiated service delivery.

Plain language summary

Differentiated service delivery (DSD) models for antiretroviral therapy (ART) enhance patient-centeredness by offering choices in service delivery options. We explored choice in DSD model enrollment at 42 public sector clinics in Malawi, South Africa, and Zambia. From 09/2022-05/2023, we interviewed people receiving HIV treatment and healthcare providers, asking participants whether they had a choice about DSD model enrollment and whether providers offered this choice to their patients. We analyzed the data to identify differences in how people receiving HIV treatment reported being offered a choice. 1049 people receiving HIV treatment participated: 409 from Malawi, 362 from South Africa, and 278 from Zambia, alongside 404 providers (110 in Malawi, 175 in South Africa, and 119 in Zambia). 4% in Malawi, 17% in Zambia, and 47% in South Africa reported being offered a choice to enroll in a DSD model. Few actively sought to join a DSD mode (Malawi 10%, South Africa 19%, and Zambia 13%)—but many consented to enroll even when not explicitly offered (Malawi 66%, South Africa 80%, Zambia 59%). Over 90% were happy with their current DSD model. Among providers, 64% in Malawi, 80% in South Africa, and 59% in Zambia reported offering patients the choice to enrol in a DSD model or remain in conventional care. Most people receiving HIV treatment in our study did not report being offered a choice to join a DSD model despite providers claiming they offered one. Further research is needed to understand how offering choices could improve health outcomes and satisfaction with care.

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Conflict of interest statement

The authors report no competing interests. PLM and RN are employees of the Ministry or Department of Health in their respective countries and thus have some supervisory authority over the study sites. This paper has been uploaded to MedRxiv as a preprint: https://www.medrxiv.org/content/10.1101/2024.12.09.24317166v1#:~:text=Over%2090%25%20of%20clients%20in,or%20remain%20in%20conventional%20care

Figures

Figure 1
Figure 1
Continued.
Figure 1
Figure 1
(a) Survey participants’ self-reported offer of choice in enrolling in their current DSD models, by country (n=1049). (b) Survey participants self-reported timing of last discussion regarding DSD model choice with provider, by country (n=1049).
Figure 2
Figure 2
Health provider self-report of offer of choice in DSD model participation to ART clients, by country (n=404).
Figure 3
Figure 3
Clients to whom information about DSD models is conveyed, provider self-report (n=394).
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