A sequential, adaptive model of differentiated service delivery to reach persons living with HIV who are lost-to-follow-up or who have detectable viral load

ABSTRACT While there is no effective cure for HIV, taking HIV medicine called antiretroviral therapy (ART) can reduce the amount of HIV in the blood of people with HIV to almost complete suppression of viral replication and undetectable viral load. In South Africa, the vast majority of ART is dispensed through clinics. The COVID-19 pandemic demonstrated how disruptions to health care services can impact individuals' access to care. However, novel approaches to health care delivery have allowed providers to continue to meet the needs of their patients throughout the pandemic. Specifically for HIV care, home delivery of ART has the potential to both increase coverage for decentralized ART delivery in rural communities and be cost-effective in comparison to clinic-based ART refills. In the pilot Deliver Health Study, we demonstrated that home delivery and monitoring of ART, including a client fee for service, increased viral suppression compared to standard clinic-based services. Furthermore, home delivery of ART would likely reduce the number of people commuting to clinics with personal vehicles and public transportation, decrease overall emissions, and have a positive impact on environmental health. The goal of the proposed Diversity Supplement is to compare the cost, cost-effectiveness, environmental impact, and COVID-19 service disruptions of two different ART resupply mechanisms on viral suppression in KwaZulu-Natal, South Africa. This project will utilize data from a pilot study conducted in 2020, the Deliver Health Study, to inform the ongoing sequential multiple assignment randomized controlled trial of scalable interventions for antiretroviral therapy delivery (SMART ART) in South Africa co-led by Dr. Ruanne Barnabas at the University of Washington in Seattle and Dr. Alastair van Heerden at the Human Sciences Research Council in South Africa.