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Dr Helen Bygrave: Differentiated Service Delivery Can Work Across More Than HIV


Differentiated service delivery models can be employed to incorporate other chronic disease needs for patients with HIV, emphasized Helen Bygrave, MD, Médecins Sans Frontières (Doctors Without Borders).

With the delivery of antiretroviral therapy (ART) now simplified, we need to think how differentiated service delivery (DSD) models can incorporate other chronic disease needs—in particular, hypertension and diabetes. DSD was never just about HIV, because we need to look at our patients as whole people with multiple needs, emphasized Helen Bygrave, MD, chronic diseases advisor for the Médecins Sans Frontières (Doctors Without Borders) Access Campaign.


How can DSD improve outcomes among persons living with HIV who may have comorbid hypertension and diabetes?

The reality is that, in particularly hypertension, if we look at the prevalence of hypertension across the countries which have high HIV prevalence: In the general population, we're looking at generally 1 in 4, 1 in 5 people will have an elevated blood pressure. And prevalence of diabetes ranges between usually 3% and 6% or 7%. Now, if you drill down and look at the prevalence specifically in people living with HIV, it is really often reflecting that general population prevalence, and there are some nice data from Eswatini recently showing that 25% of people living with HIV have an elevated blood pressure that would require attention and some quite nice modeling work from Kenya showing that 62% of people living with HIV there have at least 1 or more NCDs [noncommunicable diseases] that need addressing.

So whilst we’ve been simplifying care through differentiated service delivery [DSD] for ART delivery, many of our cohort is aging. In Kenya, 23% are older than 50 years old. Similarly, 18% in Zambia are now older than 50 years. So, as we have simplified their ART delivery, they have other needs.

It's no good giving 6 months of ART, whilst they're still coming every month to collect medicines for hypertension or diabetes, for example. So I think the question we're now posing across our programs is, how do we make this care person centered, and can we integrate all of those chronic disease needs into our service delivery models? Do we have the ability, through our supply chains, to align the supply of hypertension medicines, diabetes medicines, with our ART, for example? Do we have our staff adequately trained to be able to provide ART, hypertension, and diabetes care? What are the gaps there in terms of health care worker provision?

Importantly, and I think there is a real call from this now from civil society, is that we need to look at the person as a whole and recognize that there are these multiple needs, and I think DSD and thinking about how we how we can integrate chronic diseases is an opportunity. DSD was never really designed, in terms of its formulation, just for HIV. It was kind of a model that was thought through for chronic disease. We can apply the principles of where we deliver care, who delivers care, and when we deliver it to any chronic disease, whether that's HIV, hypertension, or diabetes.

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