GLOBAL FUND LAUNCHES ITS DIFFERENTIATED SERVICE DELIVERY STRATEGIC INITIATIVE

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Download PDF In November 2020, the Global Fund announced a call for applications for long term technical service providers for the human immunodeficiency virus (HIV) differentiated service delivery (DSD) Strategic Initiative. This call follows a Global Fund decision made in November 2019 that approved an allocation of $15 million for the 2020-2022 allocation period for an HIV DSD Strategic Initiative to…

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Article Number: 9

Support to scale up modalities to improve better targeted HIV testing and treatment

ABSTRACT Although later than initially planned, the Global Fund has launched one of 19 Strategic Initiatives through a call for proposals for technical service providers to deliver the Differentiated Service Delivery Strategic Initiative. The Differentiated Service Delivery investment will focus on achieving public health impact through scaling-up Differentiated Service Delivery models or service delivery adaptations for testing and treatment in a maximum of ten countries, and providing learning and tools for portfolio-wide implementation in the next funding cycle.

In November 2020, the Global Fund announced a call for applications for long term technical service providers for the human immunodeficiency virus (HIV) differentiated service delivery (DSD) Strategic Initiative. This call follows a Global Fund decision made in November 2019 that approved an allocation of $15 million for the 2020-2022 allocation period for an HIV DSD Strategic Initiative to address gaps in HIV testing and treatment. The Board approved the DSD Strategic Initiative to catalyze more effective use of country allocations, integrate cost-effectiveness considerations in HIV program implementation and ensure that national targets are achieved.

Differentiated service delivery is a responsive, client-centered approach that simplifies and adapts HIV testing and treatment services to better serve individual needs and reduce unnecessary burdens on the health system. Yet, despite the availability of guidelines and frameworks to assist countries in developing DSD testing, treatment and care models, countries have struggled to operationalize them.

The DSD Strategic Initiative is one of 19 workstreams under Global Fund Strategic Initiatives that total $343 million in the 2020-2022 allocation period. Strategic Initiatives are one of three modalities for funding catalytic investments. They support the success of country allocations but cannot be funded at the country level due to their cross-cutting or off-cycle nature. However, they are vital to ensure country allocations deliver according to the Global Fund Strategy. The other two modalities are multi-country approaches and matching funds.  Matching funds are designed to inspire innovation and ambitious evidence-based programming approaches to maximize impact in specific strategic priority areas.

Ten countries will benefit from the Global Fund DSD Strategic Initiative

The DSD investment will focus on achieving public health impact through scaling-up DSD models or service delivery adaptations for testing and treatment in a maximum of ten countries, including eight with an in-depth focus and two with a thematic focus, and providing learning and tools for portfolio-wide implementation in the next funding cycle.

Four of the ten countries (Mozambique, Nigeria, Tanzania and Zambia) are guaranteed funding for the entire implementation period from 2021 to 2023. The other six countries (Cameroon, Côte d’Ivoire, Ghana, Guinea, Indonesia and the Philippines) will receive a continuation of funding for the entire three-year cycle if they can demonstrate progress against implementation milestones by the middle of the implementation period.

Included in the $15 million budget is $1.96 million for WHO to provide the global support component of the Strategic Initiative and $1.2 million retained by the Global Fund Secretariat to complement capacity to manage the Strategic Initiative.

A related $25 million matching fund investment has also been provided to Cameroon, Mozambique, Nigeria, Tanzania and Uganda for the 2021-2023 implementation period beyond their core allocations to support the scale up of HIV-self testing in the context of differentiated HIV testing services. These funds were made available to incentivize the programming of the country allocation towards HIV testing. An initial $14.5 million ($2.9 million per country) was made available to the five countries to be matched in full with grant allocations. An additional $10.5 million will be made available for Year 3 contingent on mid-cycle performance against targets.

The DSD Strategic Initiative objectives and implementation status

The launch of the DSD Strategic Initiative started with country consultations

Implementation was originally envisaged to start in January 2021 but has been delayed due to the COVID-19 pandemic. Prior to implementation start, the Global Fund and partners facilitated country consultations to agree on existing gaps and opportunities, priority areas and populations to be targeted; and develop country workplans for the duration of the Initiative. Country consultations have been concluded and implementation workplans are almost final. Implementation is on schedule to commence in March 2021.

Objectives of the technical support

The overall aim of the Strategic Initiative is to support the provision of expert technical assistance to country programs (for policy and programming implementation) to ensure DSD models, adaptations and/or innovations are developed and scaled up. It is expected that this will improve the efficiency and quality of services, ultimately reducing morbidity and mortality, and community transmission of HIV, through early diagnosis, high treatment coverage, treatment retention and viral load suppression.

The main objectives of the Initiative are to: (i) develop and revise national policies and plans that support and enable expansion of DSD; (ii) scale up DSD models for priority populations, including monitoring and evaluation; (iii) strengthen facility and community implementers’ capacity for implementing DSD approaches and data collection, use and reporting; and (iv) identify and articulate lessons learned and evaluate approaches for broader application to National Strategic Plans for HIV and the wider Global Fund HIV portfolio.

Technical service providers will deliver one or more of the following three areas:

• Lot 1: Technical assistance ― leveraging evidence, best practices and tools.
• Lot 2: Technical assistance ― country support for scale up of DSD models or service delivery adaptations (local organizations).
• Lot 3: Learning and Evaluation.

The DSD Strategic Initiative will have two main components

Global Level Quality Assurance, Technical Guidance and Oversight

The World Health Organization (WHO) are implementing this component with support from the Joint United Nations Programme on HIV/AIDS (UNAIDS). It is facilitating learning and national dialogue on differentiated approaches or adaptations to service delivery, and coordinating partner inputs into the initiative through a DSD technical working group (TWG).

The DSD TWG, hosted by the Global Fund and WHO, comprises a core group of Global Fund partners established to guide DSD activities across organizations from 2021 to 2023. They provide technical inputs into the DSD Strategic Initiative including advising on country priority setting and planning, identification of synergies and sharing of lessons learned across organizations. Other partners in the TWG include the Bill and Melinda Gates Foundation, the Center for Disease Control, the Department of Defence, UNAIDS, the United Nations Children’s Fund, the Unitaid Global Health initiative, the United States President’s Emergency Plan for AIDS Relief/Office of the Global AIDS Coordinator, and the United States Agency for International Development.

WHO will ensure service delivery models or adaptations adopted and implemented by the target countries are in line with normative technical guidance. It will also oversee learning and best practice exchange, technical assistance optimization and alignment. WHO will work closely with technical service providers that have been selected by the Global Fund.

Country Level Technical Support

The service providers will provide ongoing, iterative technical support for DSD approaches and innovations in the following areas:

• Differentiated HIV Testing Services (HTS): support countries to introduce and scale up HTS modalities that have demonstrated high impact in mobilization, service delivery and linkage to prevention and care for the target populations prioritized. These services include testing by a health care worker in the health facility, testing in the community or workplace, HIV self-testing, assisted partner notification, index testing and social network approaches.
• Differentiated ART: catalyzing the accelerated scale-up of facility-based, community-based, workplace and other effective ART models across the HIV program. The ART models include multi-month dispensing/fast track refills, adherence clubs, community or client ART distribution.
• Advanced HIV Disease (AHD) Management: this encompasses services that address the specific needs of people with advanced HIV disease and define a package of interventions aimed at reducing HIV-associated morbidity and mortality. Under this sub-component, the selected service providers will work with the target countries to ensure the consistent implementation of AHD diagnostic and care protocols ― their development, training in their use and implementation ― in facilities providing ART.

Better targeted interventions are needed to close gaps in HIV testing and treatment

Despite the progress made in global HIV treatment scale up, significant challenges remain in both testing and treatment. Inadequacies in early diagnosis, initiating and continuing treatment, and achieving viral suppression, are most severe for men, key populations, adolescents and children. With the anticipated long trajectory of the COVID-19 pandemic, the need to adapt HIV service delivery has become even greater. Adjustments and innovations are needed to improve the reach of populations lagging behind, ensure treatment continuity and quality, and mitigate the impact of COVID-19 ― such as service interruptions, lack of access and congestion of health facilities ― on testing and treatment services.

Differentiated testing aims to increase efficiency, effectiveness and equity, and to find the highest number of positives with the lowest number of tests. It helps identify people who, for multiple reasons, do not readily access routine or standard service. Differentiated and innovative services for testing such as index- and self-testing offer additional opportunities to increase programmatic efficiencies and improve effectiveness where needed. Index-case-testing targets family members or partners of a known HIV-infected client and encourages them to test for HIV. These services enable countries to optimize already constrained health budgets and donor resources to achieve the greatest impact.

Differentiated treatment drives quality ART services that improve care for those who need it the most. It also responds to client preferences and reaches those outside the health system. Innovations in DSD models for treatment may include interventions such as multi-month prescriptions, treatment adherence clubs, community antiretroviral drugs (ARV) groups and points of distribution, and other facility models. These models have demonstrated consistent improvement in patient engagement and retention in care and, ultimately, viral suppression, while freeing up time for those presenting with advanced disease. However, success is only possible with the right policies in place, national coverage and improved national disaggregated reporting. Strengthening the supply chain, laboratory services, community service delivery, social protection, and monitoring and evaluation, systems are also critical to the success of this approach.

Further reading:
fundingmodel_2020-2022strategicinitiatives_list_en.pdf (theglobalfund.org)