Adjetey et al. BMC Health Services Research (2019) 19:95 https://doi.org/10.1186/s12913-019-3878-7 RESEARCH ARTICLE Open Access Differentiated service delivery: a qualitative study of people living with HIV and accessing care in a tertiary facility in Ghana Vincent Adjetey1, Dorcas Obiri-Yeboah2* and Bernard Dornoo3 Abstract Background: In 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) set out a treatment target with the objective to help end the AIDS epidemic by 2030. This was supported by the UNAIDS ’90-90-90’ target that by 2020, 90% of all people living with HIV (PLHIV) will know their HIV status; 90% of all those diagnosed with HIV will be on sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will have viral suppression. The concept of offering differentiated care services using community-based models is evidence-based and is suggested as a means to bring this target into reality. This study sought to explore the possible predictors and acceptability of Community-based health service provision among PLHIV accessing ART services at the Cape Coast Teaching Hospital (CCTH) in Ghana. Methods: A qualitative study, using 5 focus group discussions (FGD) of 8 participants per group, was conducted at the HIV Clinic in CCTH, in the Central Region of Ghana. Facilitators administered open-ended topic-guided questions. Answers were audio recorded, later transcribed and combined with notes taken during the discussions. Themes around Facility-based and Community-based service delivery and sub-themes developed from the codes, were verified and analyzed by the authors, with the group as the unit for analysis. Results: Participants expressed preference for facility–based service provision with the construct that, it ensures comprehensive health checks before provision of necessary medications. PLHIV in this study wished that the facility- based visits be more streamlined so “stable clients” could visit twice in a year to reduce the associated time and financial cost. The main barrier to community-based service delivery was concerns about stigmatization and abandonment in the community upon inadvertent disclosure of status. Conclusions: Although existing evidence suggests that facility-based care was relatively more expensive and time consuming, PLHIV preferred facility-based individualized differentiated model to a community-based model. The fear of stigma and discrimination was very strong and is the main barrier to community-based model among PLHIV in this study and this needs to be explored further and managed. Keywords: PLHIV, Differentiated Model of Care, Ghana, ART * Correspondence: [email protected]; dobiri- [email protected] 2Department of Microbiology and Immunology, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Adjetey et al. BMC Health Services Research (2019) 19:95 Page 2 of 7 Background Health systems must tailor their anti-retroviral treat- At the end of 2015 there were 36.7million people living ment (ART) services such that the client comes first but with HIV globally of which less than half (46%) were on with due cognizance of their human and financial re- therapy. In Ghana, there were an estimated 313,063 of source constraints. In Ghana ART service delivery across people living with HIV (PLHIV) at the end of 2017 with the country has mainly been facility based per the na- 125,667 on antiretroviral therapy (ART) [1]. In 2014, the tional guidelines [8]. This approach implies that clients Joint United Nations Program on HIV/AIDS (UNAIDS) will have to visit the ART clinics in the health facilities set out an aspiring treatment target with the objective to regularly in order to receive their medications and ne- help end the AIDS epidemic by 2030. This ambitious cessary follow up care, Currently, Ghana is in the final target was given the needed impetus by the UNAIDS stages of developing a guideline for differentiated HIV ’90-90-90’ target which was to the effect that by 2020, care for the country which aims at improving care and 90% of all people living with HIV will know their HIV outcomes keeping in mind the ’90 90 90’ targets. Yet, status; 90% of all people with diagnosed HIV infection there is limited research evidence from the country on will receive sustained antiretroviral therapy; 90% of all the views of PLHIV in the country regarding their pre- people receiving antiretroviral therapy will have viral ferred models of care. suppression. Levesque el at developed a conceptual framework on There are many challenges affecting access to, and the access to health care which identifies relevant determi- quality of care for HIV infected clients, including long nants that impact access from a multilevel perspective [9]. travelling distances, high transportation costs, long wait- Their revised conceptual framework reveal that factors af- ing times in health facilities, concerns of confidentiality, fecting access to health include those which are related to issues of stigma and discrimination and poor attitudes of the health system, institutions, organizations and pro- some healthcare workers towards clients. [2]. A lot of viders as well as individual, household, community and work is therefore going into HIV testing and diagnosis, population level factors. This conceptual framework forms and making therapy easy and accessible for clients. the basis of this study to explore the possible predictors As part of differentiated care, community health and acceptability of Community-based health service workers, ART clubs and other models of community ser- provision among People living with HIV (PLHIV) acces- vice delivery are increasingly being used by HIV-treatment sing ART services at the Cape Coast Teaching Hospital in programs [3]. It has been recommended that Ghana. community-based models of ART delivery be used to sup- port ART expansion and retention in resource limited set- Methods tings [4, 5]. Various models have been proposed and tried Study design in different settings. These include facility-based individ- A qualitative study using focus group discussions (FGD) ual, out –of-facility individual, health care worker man- to explore the notions of clients on community-based aged group and client-managed group models. [4, 6, 7]. delivery of HIV care services as opposed to facility-based For instance, Uganda has the Community Drug Distribu- care was conducted. Five (5) FGDs were conducted in tion Points (CDDP) for eligible clients (more than 10 July 2017 with eight (8) participants in each group. weeks on ART, CD4 of more than 350 cells/mm3, and 95% adherence) to pick up their medications near their Study setting homes instead of travelling for long distances and queuing The study was conducted at the HIV Clinics of the Cape for hours [7]. The community-based Adherence Club Coast Teaching Hospital (CCTH) situated in the Cape (CAC) in Cape Town, South Africa is an example of a Coast Metropolis of the Central Region of Ghana. Estab- health care worker managed model. Patients who have lished in 2006, this was the first HIV/ART clinic in the been adherent to their treatment regime for more than 12 Central Region of Ghana and serves as the referral hos- months and show viral suppression are accepted. They pital for the entire region and beyond. The combined meet about twice a month for “group counselling, brief HIV care clinics serve an average of 120 clients (chil- symptom screen and distribution of prepackaged ART” at dren, adolescents and adults) per week. an agreed community location [4]. Experience with Mozambique’s Community ART Group (CAGs), an ex- Study population ample of a client-managed group, showed that clients felt Sampling, and data collection procedure more empowered and involved in their care and in the Focus group participants were randomly selected from creation of a supportive environment leading to improved the list of clients accessing services at the CCTH, Ghana. ART retention. In addition, it led to health services being The participants were adults, 18 years and above and redirected towards the community and it’sstrengthening were grouped according to gender to explore possible efforts [2]. gender specific constructs. Persons under 18 years were Adjetey et al. BMC Health Services Research (2019) 19:95 Page 3 of 7 excluded since they were minors and tend to depend on “home” service delivery, inadvertent disclosure with result- adult care givers for their clinic visits and health care in ant stigma and discrimination, and challenges with general. A trained facilitator led the focus group discus- organization of community-based service. These are pre- sions using the preferred language of the participants sented in the results section and then discussed. (mainly Fante), and a topic guide of open-ended ques- tions. A second trained facilitator documented the group Ethical issues dynamics, general atmosphere, and non-verbal cues of This study was approved by the Institutional Review the participants. The FGD guide explored participant’s Board of the University of Cape-Coast (UCCIRB /EXT/ experiences with ART service delivery so far since their 2017/03), Ghana. Permission to undertake the study at HIV diagnosis. The guide then elicited views on and spe- the HIV Clinics of the hospital was sought and granted cific benefits and challenges with the current service de- by the hospital management.