Abstract
Background: Ensuring uninterrupted HIV treatment for female sex workers (FSWs), who face a disproportionately high HIV burden, is crucial for curbing HIV transmission and disease. Structural, social, and legal barriers impede their access to HIV services. The differentiated service delivery (DSD) model, designed to tailor and decentralise HIV services, aims to overcome these barriers. However, the impact of the DSD model for HIV treatment uptake among FSWs in sub-Saharan Africa (SSA) is not well documented.
Objectives: To assess the implementation of the DSD model in improving HIV treatment outcomes among FSWs in SSA.
Method: A systematic review literature was conducted to include available records from January 2019 to March 2024, using electronic databases such as EBSCOhost, Science Direct, SCOPUS, PubMed Central, and others. Ten studies met the eligibility criteria for inclusion for the review. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with the International Prospective Register of Systematic Reviews (ID: CRD42023440551).
Results: The uptake of HIV treatment services varied depending on whether the DSD model was facility-based, community-based, or a combination of both. Community-based models were generally preferred and led to better treatment outcomes due to their comprehensive health services.
Conclusion: To improve HIV treatment outcomes for FSWs in SSA, it is essential to strengthen DSD model implementation, access, and utilisation, particularly at the community level.
Keywords: female sex workers; key populations; differentiated service delivery model; HIV treatment outcomes; sub-Saharan Africa.
What this study adds: This systematic review has important implications for practice, and research as it enhances understanding of the barriers and facilitators of the DSD models (community, facility and mixed-model) implementation and utilisation in Sub Saharan Africa. Community-based models comprised of a comprehensive health service package which improved access to HIV treatment and outcomes among FSWs.
Introduction
In 2023, there were 39.9 million people living with HIV (PLHIV) worldwide.1 While 51% of new HIV infections occurred in sub-Saharan Africa (SSA), 94% of infections occurred outside SSA.1 In eastern and southern Africa, young women and girls aged 15–24 years face a 2.3% higher HIV prevalence. Key populations, including female sex workers (FSWs) and their clients, men who have sex with men (MSM), people who inject drugs (PWID), and transgender people (TG) and their sexual partners accounted for 70% of the world’s HIV infections.2 Sex workers have a 3% higher rate of HIV prevalence.1 FSWs often engage in unprotected sex and transactional sexual activity with several partners, and account for 40% of the HIV prevalence in SSA.3 Moreover, the estimated HIV prevalence among the FSW population is 10- to 20-fold greater than the general population, notwithstanding significant geographical variance.4 For instance, in Rwanda, 50% of FSWs are living with HIV.4 In Uganda, HIV prevalence among FSW is 33% – 37%, compared to 9.5% among the general female population.5
The risk of HIV acquisition among key populations, especially FSWs, requires an understanding in the context of economic hardship, violence, and criminalisation of sex work.3 The standard care of delivery is associated with unmet needs of HIV services for FSWs.6 It involves a uniform approach to healthcare, where all patients follow the same care of HIV treatment, regardless of their unique needs or circumstances.7 This model typically requires patients to visit healthcare facilities frequently for clinical check-ups, medication collection, and ongoing care.8,9 The services for HIV are centralised, delivered by healthcare providers in structured clinical environments, offering limited flexibility in terms of scheduling.9 As a result, FSWs may face challenges such as long waiting periods, inflexible hours, stigma, and inability to access consistent HIV care.6,7 As a result, in ensuring that there is uninterrupted delivery of HIV treatment services to curb transmissions and new infections amongst key populations, the differentiated service delivery (DSD) model was introduced to address barriers towards treatment access for continuity of services.10
The DSD model provides an alternative to the standard care of HIV treatment delivery, which has historically been provided in fixed-site clinics and necessitates at least four patient visits to the clinic per year, if not more.11 This model is designed to be patient-centred and to enhance the efficiency of health systems by adapting HIV care to meet patients’ needs and the capacities of health services.6,9 Unlike the standard approach, which applies uniform care to all patients, the DSD model tailors HIV services based on a patient’s antiretroviral therapy (ART) stability, reducing clinic visits and offering decentralised care.9 While the DSD model has shown positive effects on HIV outcomes in SSA in the general population, its specific benefits for FSWs remain less evident.12 FSWs face distinct challenges, such as social, structural, and legal barriers, which require more focused research to understand how the DSD model impacts their HIV treatment outcomes.13
The DSD models include community-based, facility-based and mixed models. Community-based models, such as community ART groups (CAGs), facilitate group medication collection and drug distribution by community health workers.6 Task-shifting empowers community health workers to deliver specific services, improving access and reducing healthcare burdens.14 The facility-based model provides quick medication access and extended appointment intervals for persons that are adherent to ART. Additionally, peer-led programmes offer support and education,9 while mobile clinics and outreach services extend care to underserved communities.15 Family-oriented care integrates HIV services with maternal and child health.6,15 The purpose of this article is to assess the implementation of the DSD model in improving HIV treatment outcomes among FSWs in SSA.
Research methods and design
Approach
The systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to ensure validity and reliability (see Online Appendix 1 for the PRISMA Checklist).16 The review was registered on the International Prospective Register of Systematic Reviews (ID: CRD42023440551).
Search strategy
The search strategy was developed using the Population, Intervention, Comparison, and Outcome (PICO) framework, Boolean operators (‘AND’ and ‘OR’), truncation (‘*’ and ‘()’), and Medical Subject Heading terms. The systematic review includes peer-reviewed published and full-text-accessible articles of primary studies conducted in SSA on implementation of the DSD model to enhance HIV treatment among FSWs. A combination of key concepts (main key terms and their synonyms) was used. In searching, the Boolean operator ‘OR’ was used to link each key concept to their synonyms, and ‘AND’ to combine main key terms, while the truncations were used to separate or emphasise the synonyms and main key terms. The search terms and strategy were combined in the manner presented in Table 1.
The electronic databases included EBSCOhost, Science Direct, SCOPUS, PubMed Central, PLOS Global Public Health, PLoS ONE, Crossref, Medline, Google Scholar, and Lancet. Additional information was sought from multilateral organisations such as the Joint United Nations Programme on HIV/AIDS, World Bank, US Centers for Disease Control and Prevention, and Global Fund. Reports and unpublished articles from these organisations were also reviewed. In addition, the reference list of selected studies was also consulted to ensure literature saturation.
Eligibility criteria
The PICO framework was used to guide and establish the eligibility criteria. The key elements of the PICO framework were used to define and structure the inclusion and exclusion criteria (see Table 2). The search strategy included HIV treatment outcomes. The search was done to include peer-reviewed articles published between the years 2019 and 2024 to understand the impact of the DSD model on HIV treatment outcomes among FSWs in SSA. The review included studies reporting on FSWs on ART aged 15 years and older, as there is growing evidence demonstrating that adolescent girls and young women report being involved in transactional sex.17
| TABLE 2: Inclusion and exclusion criteria of the literature for the systematic review. |
Study selection
Endnote and Covidence tools were used to remove any duplicates and manage the screening process using the purposely designed eligibility criteria mentioned above. The tools were also used to store and organise the references. Following the removal of duplicate articles, two reviewers (L.M. and A.A.) independently screened titles, abstracts, and full text to exclude articles that did not meet the inclusion criteria. The third (E.P.) and fourth (R.N.P.-M.) reviewers supervised the selection process through periodic checks to ensure the quality of the process. Disagreements were resolved by the team through consensus. The team held meetings to resolve conflicts using the Covidence software tool. The quality and bias of the included articles were assessed utilising the Critical Appraisal Skills Programme (CASP) tool in Online Appendix 2.
Data extraction
Ten studies included in the review were extracted in accordance with the aims of this review by utilising the data extraction tool in Covidence.18 Two authors (L.M. and A.A.) independently reviewed and extracted each article before jointly reviewing the extracted data to reach a consensus. The literature reporting on the use of DSD models for HIV treatment among FSWs were included. Studies that reported on HIV treatment implementation, ART service delivery, retention to care, and viral load testing coverage were also considered. The information extracted was synthesised based on relevant information on study characteristics, the DSD model type, purpose of the DSD model, challenges, and success in utilising the DSD model for HIV treatment.
Quality assessment
The qualitative studies were assessed utilising the CASP tool to verify the quality of the selected articles and to screen them for bias (see Online Appendix 2).19 The quality assessment tool for observational cohort and cross-sectional studies (see Online Appendix 3)20 was used to assess the cross-sectional studies. Two reviewers (L.M. and A.A.) independently evaluated each article before jointly verifying the results.
Review selection
The identification, screening, eligibility, and inclusion are summarised in Figure 1. There were 2416 studies identified, including one grey literature study, and 1715 of the 2416 studies were removed as duplicates. The remaining 701 articles were screened for title and abstract, and 668 articles were excluded as they did not meet the eligibility criteria stated in Table 2 and Figure 1. As a result, 10 eligible articles were identified and included in the study.
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FIGURE 1: Preferred reporting items for systematic reviews and meta-analysis. |
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Ethical considerations
As no original data were collected, ethical approval and consent for participation were not sought for this review. However, this review is part of the doctoral research undertaken by Lifutso Motsieloa (L.M.), which has received approval from UJ Faculty of Health Science Research Ethics Committee (reference no.: REC-2519-2024).
Results
The review included an initial search that identified 2416 records, including one grey literature study, and 1715 duplicates were identified by Covidence. A total of 701 articles and one grey literature study were included in the abstract and title screening stage. After screening for relevance, 668 records were excluded based on abstract and title screening. Subsequently, 33 records qualified for full text review and 23 studies were excluded because they fell outside the study criteria due to various reasons including wrong outcome, wrong intervention, wrong study design, wrong population, and study conducted published earlier than 2019. Ten published studies and grey literature were included in data extraction as they met the inclusion criteria for the analysis.
Study characteristics
The 10 eligible articles (nine published and one grey literature) included in the review are from five SSA countries, namely South Africa, Tanzania, Uganda, Zimbabwe, and Malawi. Table 3 presents the characteristics of the eligible articles. These articles explored a range of topics on the implementation of the DSD model, quality of care, enrolment and retention in HIV care, factors associated with retention and non-viral suppression, experiences of accessing HIV care services, and ART. The majority of the studies included were qualitative studies (n = 6), followed by programme/routine, cross-sectional study/grey literature report (n = 2), and prospective cohort design (n = 2). The sample size of the studies ranged from n = 20 to n = 617 and included FSWs aged 18 years or older. A few studies also included additional populations such as healthcare workers (HCWs) and key informants.
| TABLE 3: Summary of study characteristics. |
All the articles included were published during January 2019 to March 2024. Nine of the 10 included studies did not include an intervention. However, two articles included an intervention that stemmed from the same study, the first being an article based on the intervention,21 while the other was an embedded qualitative study of that intervention.22 Three of the 10 studies were conducted in Tanzania. The first study by Tun et al. examined the effectiveness of community-based ART delivery specifically for FSWs in Tanzania, focusing on 6-month ART initiation and adherence.21 The second study by Tun et al. explored the perceived high quality of care in community-based ART services for FSWs living with HIV in Tanzania, and investigated the effectiveness and acceptability of the decentralised approach.22 Tun et al. investigated the factors that either facilitate or hinder the linkage to HIV care and treatment among FSWs in Tanzania.22 The studies conducted in Uganda focused on challenges and successes related to enrolling FSWs in HIV care within the health facilities in Mabarar city in Uganda24; factors influencing retention and non-viral suppression among FSWs on ART from primary healthcare facilities25; views of FSWs regarding the DSD models for HIV care26; and sustained virological response and the prevalence of drug resistance among FSWs on ART.5 The study by Vu et al. compared a community-based ART model for FSWs in Malawi with centralised government-run services.27 In a study conducted in Bulawayo, Zimbabwe, the author delved into the experiences and challenges faced by FSWs when accessing HIV care services.28 In South Africa, the preferences of FSWs living with HIV in Durban regarding community-based decentralised treatment options were explored.29
Types of differentiated service delivery models for HIV treatment among female sex workers in sub-Saharan Africa
Table 4 summarises the types of DSD models indentified in this review, as well as the factors associated with the implementation of these DSD models for HIV treatment among FSWs in SSA. These studies focused on HIV care and treatment among FSWs, with a particular emphasis on improving HIV access, adherence, retention, and outcomes through the various DSD models.
| TABLE 4: Impact of differentiated service delivery model on HIV treatment outcomes and related factors among female sex workers in sub-Saharan Africa. |
Differentiated service delivery types
The community- and facility-based models included a decentralised treatment provision, a strategy that incorporates nurse-led ART care and treatment at select pick-up points in the community.8 In another study, community client-led ART delivery and community drug distribution points drop-in centres were utilised24 to further implement community-based strategies.26 Clinical and structural support services in the community were strategies to improve treatment linkage.23
Four articles focused on a facility-based DSD model.5,24,25,28 These studies on facility-based models were described as utilising mixed strategies, such as in incorporating individual management and fast-track drug refills in treatment delivery. Two articles included both a community- and a facility-based DSD model.26,27 DSD models from two studies were unidentifiable, but appeared to combine services delivered through clinics model categorised as facility-based.
Differentiated service delivery outcomes
Community-based differentiated service delivery model: A study by Tun et al. found that implementation of community-based treatment delivery has a significant positive impact on FSWs, particularly on ART retention, retention in ART services, and adherence to treatment compared to the comparison group.22 FSWs in the community-based ART intervention arm were more likely to be retained in ART services after 12 months, while participants in the comparison group had viral load tests conducted, but they did not receive the results.22 A study by Comins et al. found that the community-based DSD model could result in ART adherence and retention, reduced stigma, and enhanced confidentiality, making it a promising approach for FSWs.8 Nyato et al. highlighted positive outcomes to clinical and structural support services and treatment in the community, which include increased motivation among FSWs to access services, reduced financial barriers through transport facilitation, and improved perceptions of healthcare providers.23
Vu et al.27 showed higher rates of ART initiation, facilitated by same-day initiation and the supportive environment of drop-in centres (DICs). FSWs utilising DICs showed higher retention and viral suppression rates, indicating their effectiveness in supporting treatment adherence.
Health facility-based differentiated service delivery model: A cross-sectional study by Arinaitwe et al.24 found that HCWs and comprehensive HIV care services were identified as crucial factors to FSWs being retained in HIV care at facilities. Key factors including positive HCW’s attitudes, counselling and testing, and ART availability contributed to enrolment and retention.24 Community outreach services, especially those involving peer support, were highly effective in enrolling FSWs into HIV care, highlighting the importance of community engagement in healthcare.24 Similarly, Moyo et al.28 found that the positive and negative perceptions among FSWs towards HCWs played a crucial role in the retention of HIV services in facilities. This study also highlighted the importance of addressing socio-economic factors to improve the quality of care and enhance overall HIV care service delivery among FSWs, particularly in public facilities.28
In their retrospective study, Atuhaire et al. highlighted the importance of targeted interventions and strategies to improve retention rates.25 The authors indicated the need for careful consideration at critical early stages of implementation, as this study found a high percentage of loss to follow-up among FSWs in the first 24 months.25
In a study by Namale et al.,5 conducted at the Good Health for Women Project, where services were implemented to provide free care, intensive adherence counselling, and active patient follow-up in the clinic, several observations from this type of DSD were made. The Good Health for Women Project was a clinic accredited by the Ministry of Health in Uganda to provide ART, and started initiating ART to FSWs in January 2013. Among 591 individuals attending the clinic for ART treatment, 432 underwent viral load testing. Of these, 83% remained adherent to treatment, while 9% experienced virological failure, indicating that the services provided in the facility may have influenced the high adherence. Notably, FSWs with no education had a higher virological failure rate (15%) compared to those with secondary education and above (12%). Factors influencing virological failure included age, with a higher rate among younger participants (18% in the 18–24 age group) compared to older individuals (> 35 years, 6%). Non-adherent participants also exhibited a higher virological failure rate (16%) compared to adherent individuals (7%). Overall, 91% of FSWs were virally suppressed.5
Mixed differentiated service delivery model: Comprising facility and community-based models: A study by Arinaitwe et al.24 provides insights indicating that different DSD models cater to the diverse needs and preferences of FSWs, addressing factors such as accessibility, confidentiality, waiting times, and peer support.24,25,26 An assessment of a study looking at community-based ART services at DICs in Malawi showed improved health outcomes for the FSWs compared to traditional health facilities, offering same-day initiation, peer support, and a less crowded environment, which were preferred by FSWs.27 The two DSD models helped to reduce barriers to healthcare and improve access to ART services FSWs living with HIV.26
Impact of the differentiated service delivery model on HIV treatment outcomes and related factors among female sex workers in sub-Saharan Africa
Nine studies explored the effectiveness of various DSD models for FSWs living with HIV, focusing on HIV treatment outcomes and other related outcomes. A community-based ART study delivery by Tun et al., showed improved ART initiation, retention at 12 months, and reduced ART discontinuation rates.22 However, participants in the comparison group did not receive feedback on their viral load test results, potentially impacting adherence.22 Similarly, Arinaitwe et al. highlighted improved retention in HIV care for FSWs in Uganda, but noted limited access to comprehensive services beyond HIV care.24
In South Africa, Comins et al. found that 50% of FSWs successfully engaged in ART, with 90.9% achieving viral suppression through community-based distribution models. Retention rates remained high initially but dropped over time, with younger FSWs (< 25 years) more likely to discontinue treatment.8 A study by Atuhaire et al. similarly reported that 50% of FSWs in Kampala, Uganda, were engaged in ART, though no additional outcomes were discussed.25 Another study by Atuhaire et al. emphasised the importance of retention in HIV care, with increased access to care through differentiated models.26
Moyo et al. examined the experiences of sex workers in Bulawayo, Zimbabwe, and found higher retention rates, improved access to HIV services, and increased knowledge about HIV treatment and prevention methods.28 In Malawi, Vu et al. compared ART initiation and retention between DIC and health facility models, finding higher initiation and retention rates at DICs. Viral suppression rates were also high across both models, although adherence challenges were noted, particularly among those relying solely on DIC services.27
In Tanzania, high levels of ART adherence and viral suppression were reported, but concerns were raised regarding viral load rebound, drug resistance, and declining CD4 counts among some FSWs. The study highlighted ongoing HIV transmission concerns despite treatment efforts.23 Finally, Namale et al. observed high virological suppression (91%) and ART adherence (83%) in Uganda, although younger FSWs experienced higher rates of virological failure and drug resistance.5 Tun et al. also noted high ART initiation and adherence in Tanzania, but highlighted barriers to long-term care retention.21 Only Atuhaire et al. did not provide detailed HIV treatment outcomes beyond ART engagement.25
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