Introduction

Nigeria is among the countries that have the highest burden of HIV globally [1]. With an estimated 1.9 million people living with HIV (PLHIV) [2], effective management and treatment remain critical priorities for public health initiatives in the country. In 2016, Nigeria adopted the ‘test and treat’ which stipulates a rapid ART initiation for all persons who test HIV positive, and the subsequent implementation of the HIV ‘SURGE’ resulted in a rapid scale-up of HIV case finding and increased number of Persons Living with HIV placed on treatment thereby placing a higher-than-usual burden on the fragile healthcare system [3–6]. Differentiated Service Delivery (DSD) model of care was among the innovative approaches adopted to address the challenges associated with a high volume of persons in HIV care and treatment in a country with scarce resources [7].

Differentiated Service Delivery refers to a patient-centered approach to HIV care, aiming to tailor services to the diverse needs of PLHIV [8]. These include various models, such as community-based care, fast-track drug refills, and task-shifting responsibilities to lower-level healthcare providers [9]. DSD programs seek to enhance treatment adherence, Continuity of treatment, and overall health outcomes for PLHIV while alleviating the strain on healthcare systems by offering flexible service delivery options [10,11]. Nigeria officially adopted the DSD approach in line with WHO recommendations in 2019 and has since scaled the implementation across the 36+1 subnational units of the federation [12]. The rapid scale-up of DSD contributed to the resilience of the HIV program in-country during the COVID-19 pandemic [12]. The COVID-19 pandemic and the resulting global response reinforced the need for countries to adopt and evolve sustainable mechanisms for managing chronic conditions, including access to ART for PLHIV. Nigeria launched the DSD Operational manual in 2021 [13] this document provides the framework for the implementation of DSD in Nigeria. The document recognizes ten different DSD models subdivided into facility-based models and community-based models. The different models of differentiated ART service delivery are summarized in Table 1 below.

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Table 1. Models of differentiated ART service Delivery in Nigeria.

https://doi.org/10.1371/journal.pone.0309254.t001

Despite the potential benefits of DSD programs which has been documented to include reducing cost of accessing care, increasing convenience for recipients of care, [14,15], and comparable outcomes with regards to retention and viral suppression among care recipients [16–18], there is a need to regularly review the effectiveness of services and activities in these settings. A critical aspect of evaluating the effectiveness of DSD involves assessing the perceptions and experiences of both PLHIV and healthcare professionals (HCWs) PLHIV. Understanding their perspectives is crucial for identifying barriers to access, adherence, and successful program implementation [19]. Therefore, exploring the perceptions of PLHIV and HCWs regarding DSD programs in Nigeria is essential for informing policy decisions, improving program design, and ultimately advancing the quality of HIV care and treatment services in the country.

The National AIDS and STI Control Program (NASCP) of the Nigeria Federal Ministry of Health collaborated with ICAP at Columbia University to assess the perspectives of healthcare professionals and PLHIV on Differentiated Service Delivery programs in Nigeria to gain comprehensive insights into the efficacy and impact of these programs on HIV care and treatment in the country.

Methodology

Results/findings

Key informant interview (KII) analysis

A total of 12 respondents participated in the KII, with an equal distribution of gender, comprising 50% male and 50% female as seen in Table 2. Among them, 33% were physicians, 25% were nurses, 17% were case managers and pharmacists, and 8% were public health specialists. Regarding experience providing ART services, 42% have less than five years, 33% between 6–10 years, and 25% more than ten years.

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Table 2. Demographics Characteristics.

https://doi.org/10.1371/journal.pone.0309254.t002

DSD coverage

The availability of DSD models in facilities varied. The most common models across most facilities were the Support group -led Facility ART group, fast track, and mother-infant pair/mentor mother-infant pair. They were followed by. Community pharmacy ART refill. The other models varied in their availability across sites, as shown in Table 3 below.

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Table 3. DSD Coverage.

https://doi.org/10.1371/journal.pone.0309254.t003

Deployment of DSD models

Several factors influenced the decision of healthcare workers and facilities to deploy different DSD models, and these factors are detailed in Table 4. The results show that client convenience and the need to reduce the healthcare worker load significantly influenced the model deployed in the facilities. However, the client’s eligibility for a specific model and the need to improve patient care were of the slightest significance. Other factors considered included distance to facilities, cost of transportation, and the need to address stigma.

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Table 4. DSD Deployment.

https://doi.org/10.1371/journal.pone.0309254.t004

Focus group discussions

The Focus Group Discussions (FGDs) convened a total of 153 participants, consisting of 79 males (51.65%) and 74 females (48.35%), providing a balanced gender representation. Respondent characteristics presented in Table 5 show that most respondents are adults (above 18 years) who have been on ART for a minimum of 1 year and are familiar with DSD models. This is in line with the recommendations in the Nigeria guidelines for DSD eligibility [20]

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Table 5. FGD Demographics.

https://doi.org/10.1371/journal.pone.0309254.t005

Discussion

In this study, we identified barriers and enablers to accessing DSD services by PLHIV and matched this with healthcare workers’ perceptions regarding DSD and clients’ preferences. The study showed that both healthcare workers and PLHIV viewed DSD as an acceptable treatment option that can lead to positive outcomes and that convenience, cost considerations, and healthcare worker attitudes are key factors that influence PLHIV experiences with DSD and can affect the decision to be devolved and retained in DSD.

Convenience of the PLHIV emerged as a key consideration for healthcare providers and clients in choosing DSD models. This correlates with findings from studies in Nigeria [21] and Ghana [22]. The convenience of having drugs delivered to their homes or picked up at their preferred time from a pharmacy was a significant consideration that influenced a positive experience for the PLHIV in these studies. Recipients of care in South Africa also reported a preference for Home delivery of medication, as it relieves them from spending a lot of time waiting in hospital queues [23]. While the Nigerian [21] and Ghana[22] studies focused on a narrower demographic of PLHIV, our study explored the perception of a wider PLHIV group. While the study from Ghana [22] focused on care recipients from a single facility, the Nigerian study [20] focused on persons devolved to DSD in Northern Nigeria. We explored the experience of persons devolved across other regions of Nigeria, including the North. This enables us to explore the social and demographic characteristics that can affect devolvement on a larger scale.

Cost had both a positive and negative effect on clients experience on DSD. While reducing the transport cost positively influenced the DSD experience, payment at the DSD service points resulted in a significant negative experience for PLHIV. Cost of service delivery was also reported as a concern by recipients accessing DSD in South Africa [15]. It is pertinent to note that while cost was identified to possibly play a role in discouraging PLHIV from accessing DSD services in certain instances, it also had a positive influence in their decision to accept services in these service points. Studies have identified DSD as a cost-saving alternative to traditional in-hospital service delivery models, especially in regions of sub-Saharan Africa where there is pervasive poverty [23]. The cost savings in these studies were more pronounced in models that incorporated 6-monthly visits. This could be from the reduced cost of transport to service delivery points. Another study also identified reduction in the cost of visit as a factor that increased acceptance of DSD by recipients of care [24]. From our analysis, we identified cost as a greater concern to women. This is similar to findings from a study in Uganda among female sex workers assessing DSD, where the cost of transport to health facilities was also identified as a barrier to the uptake of HIV services from the healthcare facilities and positively influenced their acceptance of DSD [25]. While this study focused exclusively on one of the priority populations for HIV; Female sex workers, our study explores the attitudes of Female PLHIV in the general population. These populations’ needs and experiences vary, which can influence their DSD experience. The greater concern of women with cost could be linked to the fact that women in these populations often have less income and fewer opportunities to make money. A Central Bank of Nigeria report in 2019 identified that the gender financial inclusion gap between males and females is widening. It attributed this to factors such as lower income and education levels in women. The study also attributed the reduced financial inclusion for women to other religious and cultural barriers [26]. Another report also identified that women have less employment and own less businesses compared to males in Nigeria. This is despite the presence of several regulations that promote financial inclusion for women and the country having an almost equal number of males and females in the population [27].

This study also identified concerns around confidentiality and the risk of stigma as additional factors influencing participant experience with DSD. The risk of accidental disclosure was a barrier to accessing care in community-based DSD models. This risk was heightened by poor healthcare worker attitudes during community drug delivery. The studies in Nigeria [20] and Uganda [25] referenced above also identified stigma as a barrier to accessing services in the community. Similar to the findings in the Ghana study [22], inadvertent disclosure during out-of-facility service delivery was one of the major sources of stigma to the PLHIV. Educational activities targeted at healthcare workers, recipients of care, and the general population may be of help in addressing these issues regarding stigma [28,29].

The study identified the need to continuously build healthcare worker capacity on client engagement as one recommendation for improving services at the DSD service delivery points. This training will improve healthcare workers’ ability to deliver quality services and build their capacity in non-discriminatory service provision. This may involve training healthcare workers on cognitive behavioral therapy and providing mental health and psychosocial support services.

At the program planning level, additional efforts should be made to advocate for removing or subsidizing service charges at DSD service delivery points. This will increase the acceptance of these services and reduce the financial burden on persons accessing DSD services. While a case could be made for leaving the service charge at these DSD sites, further analysis needs to be done to determine the optimal amount to be paid at these sites and the modalities for payment. If it is determined that these payments are essential, a payment option could be to incorporate these costs as part of routine healthcare costs covered by national health insurance; this will improve accessibility and further streamline the payment processes.

Feedback from the KII with service providers identified that client convenience and considerations for reducing health worker workload topped the reasons for devolving PLHIV to DSD models, while the need to address transport cost received the least consideration. This finding is similar to results from Nigeria (21) and South Africa [30] where factors such as reduction in healthcare worker workload, minimizing queues and increasing client convenience were perceived as key benefits of DSD by the healthcare providers. These were similar to findings from a scoping review [24]. While it is encouraging that healthcare providers also considered client needs and convenience in their devolvement decisions, it will be encouraging to see other considerations such as client distance to the facility and transport costs receive increased consideration during devolvement decisions. This recommendation is based on findings from the focus group discussions (FGD), where participants highlighted reducing transportation costs as one of the primary factor influencing their choice to transition to a differentiated service delivery (DSD) model. This priority is further emphasized when the socioeconomic situation of clients are put in perspective.

Conclusion

The findings of this study highlight the multifaceted factors influencing individuals’ experiences and perceptions of DSD models. While there is considerable awareness and acceptance of DSD services among participants, several challenges and areas for improvement exist. These challenges as perceived PLHIV include but not stigma, cost of care, and attitude of Healthcare workers.

Addressing these challenges will require a concerted effort from healthcare providers, policymakers, and PLHIV. Strategies to enhance healthcare worker training, optimize service delivery points to promote confidentiality, reduce financial barriers, and streamline service delivery PLHIV are crucial for optimizing DSD models and ensuring equitable access to HIV care and treatment. Furthermore, prioritizing patient-centered approaches and engaging with community-based organizations and peer networks will be essential for reaching marginalized populations and addressing gaps in HIV education and awareness. HIV program managers need to be cognizant of the role cost of services plays in the decision of PLHIV to deploy. Considerations while establishing DSD models should include the affordability of services and cost of travel to access these services. By addressing these challenges and implementing targeted interventions addressing confidentiality, accessibility, and affordability, Nigeria can strengthen its HIV service delivery system and improve health outcomes for individuals living with HIV across Nigeria.