TRAINING TOOLKIT

Differentiated service delivery

for advanced HIV disease
Courtesy of the Advanced HIV Disease Implementation Steering
Committee (AHD ISC) established by Unitaid and CHAI
Objectives

• Part 1: Principles of differentiated service delivery (DSD)

• Define differentiated service delivery
• List the three elements and four building blocks of DSD
• List the clinical characteristics in advanced HIV disease (AHD) that will
determine how service delivery is differentiated
• Part 2: DSD and AHD
• List the core components for differentiated service delivery for advanced
disease
• Use the building blocks to define a service delivery model for each category
of client with AHD
• Part 3: Case examples of DSD and AHD
• Learn from documented examples of differentiated service delivery
implemented for advanced HIV disease
Part 1: Principles of differentiated service delivery

Visit www.differentiatedservicedelivery.org
for tools, resources and more
Definition of DSD

Differentiated service delivery,

or differentiated care, is a client-centred
approach that simplifies and adapts HIV
services across the cascade to reflect the
preferences and expectations of groups
of people living with HIV while reducing
unnecessary burdens on the health
system.
Differentiated service delivery is applicable
across the HIV care continuum

DSD applies across the HIV care continuum, including linkage to prevention
The three elements
The three elements
Clinical characteristics:
Specific for advanced HIV disease
Service delivery models are differentiated according to the three
elements, including clinical characteristics. For advanced HIV disease,
this includes differentiating on whether the client is:
• Clinically unwell – admitted in IPD
• Clinically unwell (Stage 3 and 4) – ambulatory, managed in OPD/PHC
• Clinically well ( Stage 1 and 2) – ambulatory, but CD4 <200 managed
in OPD/PHC
The building blocks
An example of using the elements and building
blocks to design a differentiated model of ART
delivery for stable clients
• Clinical characteristics: clinically • Model – fast-track option
stable
• Specific population: adults
• Context: high prevalence/
stable context

Operational and Service Delivery Manual for the Prevention, Care and Treatment of HIV in Zimbabwe, AIDS & TB Programme - Ministry of Health and Child Care, Zimbabwe, February 2017
Decision-making process for determining the
building blocks
The decision-making process to determine the building blocks for clients with
advanced HIV disease – where tests are performed (OC, centralized), who performs
tests (laboratory technician, lay worker) and who can initiate specific treatments
(doctor, clinical officer, nurse) – may depend on the following factors:
• The urgency of the diagnosis – if the client is seriously unwell
• The complexity of the test being performed
• The throughput of each test – capacity to perform the volume of tests
• The ability to ensure quality control at multiple sites if only a few tests are being
performed per site
• The availability and frequency of sample transport and result delivery
mechanisms
• The policies in place for who can perform specific tests/procedures (for example,
LP) and prescribe certain medications
• The technical knowledge and capacity of different levels of HR to manage complex
cases
Diagnostics and treatments that may be
considered at a hub facility

Hub (district or sub-district)

CD4
Clinical assessment
Clinical expert/champion
Slow track
TB LAM
CrAg LFA
Fluconazole ppx
TPT
Haematology and chemistries
Lumbar puncture
Crypto treatment
Other OI treatment (TBA)
Community-based support/home visits
Welcome-back assessment for those with advanced
disease who are returning to care
Diagnostics and treatments that may be
considered at a spoke facility

Spoke facility, e.g., primary care clinic

Clinical assessment
CD4 (on site or sample referral to central
lab)
TB LAM (on site or sample referral to
central lab)
CrAg LFA (on site or sample referral to
central lab)
Fluconazole ppx
TPT
Community-based support/home visits
Welcome-back assessment for those with
advanced HIV disease who are returning
to care
Decision-making process: Point of care versus
centralized testing for a primary care clinic

HR policies allow POC testing and

prescribing of prevention package at
PHC

YES
NO
X CD4, Y LAM, Z CraG
per day
HR capacity to meet
Sample transport Consider throughput of tests
YES NO and QC feasible at
to achieve results centralized
each site
in 24-48 hours testing at hub
available
NO YES
Re-evaluate Consider POC at
policies PHC sites
Knowledge test: YES or NO

1. Does differentiated service delivery (DSD) apply to HIV testing?

2. Does DSD mean providing fewer services to the client?
3. Is DSD only for clinically stable clients on ART?
4. Can DSD principles be used to design services for key populations?
Knowledge test:

5. List the three elements of DSD.

6. List the four building blocks of DSD.
7. What are the three clinical categorizations that will help us
differentiate service delivery for clients with advanced HIV
disease?
Differentiated service delivery –
Key messages
• DSD is about client-centred care.
• DSD applies across the HIV cascade.
• Use the elements and the building blocks as the foundation to design
your service delivery model.
• For service delivery models for advanced HIV disease, you will need
to differentiate according to whether the client is:
• Unwell in IPD
• Unwell, ambulatory
• Well, ambulatory.
Part 2:
DSD and advanced HIV disease
Components to consider when designing a
differentiated service delivery model for advanced
HIV disease
• Consider the building blocks (when, where, who and what) for EACH
of the following components of a service delivery model for
advanced HIV disease:
• Identifying advanced HIV disease
• Clinical package to screen, prevent and treat advanced HIV
disease
• Rapid ART initiation and/or regimen switch
• Linkage to OPD/PHC ongoing care
• Post initiation/switch follow up
Identifying advanced HIV disease
Identifying Clinical Signs and Symptoms Performing CD4
WHEN Each clinical visit At time of HIV diagnosis
At any time in between visits in community If identified with high viral
load
Presenting clinically unwell
WHERE Facility Facility
Community Mobile clinic
Community venue
Home
WHO All facility HCW ( doctors , CO, Nurse) Lab technician
CHW , peers, CAG members and recipients Nurse
of care Lay worker
WHAT Identification of danger signs and CD4 (blood draw for
symptoms * centralised technology
with sample transport or
POC – choice dependant
on strategic mix of testing)
Clinical package to screen, prevent and treat
advanced HIV disease
Fluconazole
WHAT Xpert TB LAM Blood CRAG pre- Crypto Rx CTX TPT
MTB/Rif emptive regimen
prophylaxis
WHEN Identification For any Baseline CD4 Blood CRAG Signs According to TB screening
of TB inpatient <200 positive – LP meningitis LP local negative
symptoms at regardless of CraG CraG positive guidelines
each clinical CD4 or negative (all or if CD4
visit outpatient with <350)
TB symptoms
and CD4 < 200
(refer to local
guidelines as
this
may be
adapted)
WHERE Near POC on site (community site, PHC, hospital) IPD/ Induction IPD IPD IPD
Sample transport to testing site at peripheral OPD/PHC Consolidation OPD/PHC/ OPD/PHC/
hub or central district testing site and community community
maintenance
IPD/
OPD/PHC/
community
WHO Laboratory technician, nurse, lay worker Doctor, Doctor, Doctor, Doctor,
clinical clinical officer clinical clinical
officer, officer, officer,
nurse* nurse* nurse*
Rapid ART initiation
Initiation Switch
WHEN Within 7 days of testing for HIV or If clinical failure or CD4 <100,
re-presenting to care with the offer consider switch if confirmed with
of same-day initiation; delayed VL >1000 copies/ml according to
according to clinical condition (TB or clinical and counselling
crypto*) assessment
For IPD clients, aim to initiate
BEFORE discharge unless a delay is
clinically indicated (TB or crypto
treatment)
WHERE Hospital IPD, OPD, PHC, community Hospital IPD, OPD, PHC
WHO Nurse, clinical officer, doctor Nurse, clinical officer, doctor
WHAT First-line ART, TDF 3TC DTG; consider Second-line ART according to local
adapted VL monitoring if client is guidelines
not ART naïve
For clients re-presenting, explore
reasons for default
Linkage from IPD to OPD/PHC/community

• Why is linkage to OPD/PHC clinic/community post discharge so

crucial?
• What can you do in your current setting to ensure that linkage post
discharge occurs?
Linkage between district
hospital/outpatient/PHC/community care
Seriously Stage 3 and 4 or CD4 Seriously unwell Advanced HIV
unwell at PHC <200 PHC stable, but IPD disease identified
high risk of becoming in community
seriously unwell at
home
WHEN Clinic visit Clinic visit At discharge At any point in
between clinic visits
WHERE PHC to hospital PHC to PHC and Hospital to PHC and to Community to PHC or
community community hospital
WHO PHC clinician to PHC clinician to CHW or Hospital clinician to CHW/peer/client to
hospital clinician peer PHC clinician and PHC or hospital
CHW/peer clinician (if seriously
unwell)
WHAT Referral letter Referral letter Referral letter Recognition of red flag
Phone call Phone call Phone call symptoms
Organization of Schedule PHC Continuation of OI Escort of client to
transport appointment with client treatment facility
Request for home visit Schedule PHC
appointment with
client
ART initiation if not
started already in IPD
(unless TB/crypto)
Client initiation/switch follow up
Clinical review Tracing
WHEN Weeks 1, 2, 3, 4, 6, 8, 12 if IPD or Prioritize tracing of clients with
Stage 3 or 4 advanced HIV disease
Weeks 2, 4, 8, 12 if clinically well Trigger tracing on same day as
CD4 <200 missed appointment
WHERE Facility From facility by phone
Remote telephone consultation Physical tracing at home (if no
Community visit response to telephone call)
WHO Doctor, clinical officer, nurse Nurse, CHW, peer
Community visit
CHW/lay worker
Peer (e.g., CAG member)
WHAT Assessment of treated disease, By phone SMS or call
symptoms, side-effects; new OIs; Physical tracing
IRIS; ART adherence; consider early
VL if client is initiated after
discontinuation
Knowledge test

• List the components of DSD for a client with advanced HIV disease.
• What is the community’s role in identifying advanced HIV disease?
• When could CD4 be performed to identify advanced HIV disease?
Key messages

Each of the following components must be considered when designing

a service delivery model for a client with advanced HIV disease:
• Identifying advanced HIV disease
• Clinical package to screen, prevent and treat advanced HIV
disease
• Rapid ART/regimen switch
• Linkage to OPD/PHC/community ongoing care
• Post initiation/switch follow up
Part 3:
Case examples using the DSD
framework for advanced HIV
disease
Example 1: Clinically unwell – admitted to IPD

Identifying HIV Linkage to Post-initiation

  advanced disease Clinical package to screen, prevent and treat advanced disease Rapid ART outpatient/ follow up
PHC
Identifying Xpert Fluconazole Crypto Rx Clinical
  symptoms CD4 MTB/Rif LAM CRAG pre-
regimen TPT Initiation Switch   review Tracing
and signs emptive

Where
Any time indicated, Where Within 7 Rapid Linked to Week 2, 4 if
In community At entry to At entry to At entry to At entry to Where ASAP at indicated, days or as switch as post- stable Same day
WHEN At PHC visit hospital hospital hospital hospital indicated, rapid day 1   clinically clinically discharge Every 2 as no
At entry to       day 1   assess-   indicated   indicated clinic, then months show
hospital ment unit   to PHC

Post-
Sent to Sent to Sent to Initiated Initiated Initiated Initiated on Switched discharge By phone
In emergency District laboratory laboratory laboratory on ward on ward on ward ward on ward Done from clinic at If not
WHERE room laboratory  for urgent for urgent for urgent Continued Continued Continued Continued at Continued ward hospital for contact-
  processing processing processing at PHC at PHC at PHC PHC at PHC 6 months; ed, home
  then PHC visit

Lab Laboratory Doctor, Doctor, CO, Doctor,

WHO Doctor/CO  technician technician Laboratory
technician
Laboratory Doctor,  Doctor, CO, nurse 
technician CO, nurse CO nurse  CO, nurse  Doctor
nurse
or Doctor/CO CHW
     

Call made to
WHAT History and  PIMA CD4 PHC;
examination   referral
letter sent
 Example 2: Clinically unwell (Stage 3 and 4)
– ambulatory managed in OPD/PHC
Identifying advanced Linkage to Post-initiation
  HIV disease Clinical package to screen, prevent and treat advanced disease Rapid ART outpatient/ follow up
PHC
Identifying Xpert Fluconazole Crypto Rx Clinical
  symptoms and CD4 MTB/Rif LAM CRAG pre-emptive regimen TPT Initiation Switch   review Tracing
signs
At For any Week 2
presentation client who and 4
(depending At has not Same day Danger signs, after Week 1, 3
Presentation and At presenta- At any visit on danger presentation (if Serum CrAg already unless AfterVL
2 LP suggestive discharge and
WHEN each visit tion if TB or CD4) appropriate positive if LP NA crypto >1000 meningitis monthly
symptoms signs
or any clinic clinical signs or negative taken TPT meningitis
and cp/mL
and
(including monthly for first
CD4) or TB TBM) quarter
visit if danger negative for first
signs TB screen quarter
WHERE HIV clinic Clinic lab or Clinic lab or Clinic lab or Clinic lab or
mini-lab mini-lab mini-lab HIV clinic NA
HIV
HIV clinic HIV clinic clinic PHC to IPD HIV clinic Commu-
mini-lab nity
Nurse, CO, doctor Nurse, Nurse, CO or Nurse,
or lay worker Lab tech Lab tech Lab tech Nurse, CO or Nurse, CO Nurse, CO CO or doctor CO or CHW/
WHO (expert client or Lab tech doctor NA or doctor or doctor doctor and lay worker doctor expert
CHW) for linkage client
Home-
based
4-question TB INH (or Referral to CHW/
WHAT screen, neuro POC CD4 NA inpatient unit H&P expert
symptoms 3HP) client
visit
 Example 3: Clinically well ( Stage 1 and 2) – ambulatory but CD4 <200 managed in
OPD/PHC

Identifying advanced Linkage to Post-initiation

  HIV disease Clinical package to screen, prevent and treat advanced disease Rapid ART outpatient/ follow up
PHC
Identifying
  symptoms and CD4 Xpert LAM CRAG Fluconazole Crypto Rx TPT Initiation Switch   Clinical Tracing
signs MTB/Rif pre-emptive regimen review

Seriously Week 2, 4, 8,
12 On same
At diagnosis and unwell or Symptoms Within 7 After 2 If serum day as
WHEN each clinical visit At baseline Whenever TB TB meningitis or Serum CrAG NA  Neg TB days; same viral loads CrAG Discharged late
 Any time in symptoms   symptoms CD4 <200  positive   screen   day >1000 positive for with Stage 3 appoint-
community l and CD4 offered   copies/ml   LP or 4 Week 1, ment  
<100   2, 4, 6, 8, 12

Facility
Facility At mini-lab At district At mini-lab At mini-lab at PHC to (CHW for By phone
WHERE Community  at PHC   hospital   at PHC   PHC   PHC  NA   PHC PHC   PHC   district discharged Home
hospital   with Stage 3 visit 
or 4) 

Doctor PHC
Nurse Trained lay Laboratory Trained lay Trained lay Doctor  Doctor Doctor clinician to Doctor Coun-
WHO CHW worker   technician   worker   worker   Nurse  NA Nurse  Nurse  Doctor   hospital Nurse sellor 
Peer        clinician CHW  Nurse

Referral
WHAT   PIMA           NA        letter    
Phone call 
Group work

1. Sit in your clinic groups.

2. Nominate a group member to be rapporteur.
3. For each of the three categories of clients with advanced
HIV disease, use the building blocks framework (Slides 9
and 10) to describe how services are currently delivered
for each of the components of care.
4. Brainstorm how these building blocks may be built (if not
already offered) or adapted using the WHEN, WHERE,
WHO and WHAT approach.
5. On the flip chart provided, describe the DSD model for
advanced HIV disease that you would propose to
implement at your clinic.
Key messages

• The principles of DSD can be applied to design service delivery

models for clients with advanced HIV disease.
• The key clinical characteristics to consider are whether the client is:
• Unwell, admitted as IPD
• Unwell, but ambulatory in OPD/PHC
• Well and ambulatory in OPD/PHC.
• Use the building blocks from the differentiated service delivery
framework for each component of the advanced HIV disease
package:
• Identification
• Screening and delivering of the clinical package
• ART initiation or regimen switch
• Linkage between facilities and the community
• Post initiation/switch follow up.