Decentralized HIV care during the COVID-19 pandemic: ensuring safe community-based services

Since the start of the COVID-19 pandemic, there have been significant concerns about disruptions to the continuum of HIV care worldwide ^[1–6]. Expansion of differentiated service delivery has been proposed as one strategy to maintain safe access to HIV care ^[7], and use of differentiated services increased during the early stages of the COVID-19 pandemic ^[8]. Decentralized HIV care delivery programs providing out-of-facility care, in particular, decrease frequency of visits to healthcare facilities ^[7], minimizing exposures to COVID-19 and allowing continuity of HIV care during lockdowns and other restrictions. However, providing decentralized, out-of-facility HIV care during the pandemic requires access to COVID-19 information, capacity to screen patients for COVID-19 symptoms, and adequate supply of personal protective equipment at all points of care. Supporting staff and ensuring access to these resources may be more difficult in community-based sites.

We sought to evaluate perceptions of personal and facility preparedness among healthcare workers at primary health clinics and community-based pick-up points participating in a decentralized antiretroviral therapy (ART) delivery program in KwaZulu-Natal, South Africa. The Central Chronic Medicines Dispensing and Distribution program allows stable, virologically suppressed patients to collect ART at community-based pick-up points, such as private pharmacies and churches ^[9]. We administered a telephone questionnaire to a convenience sample of staff in primary health clinics in April and May 2020 and staff in clinics and community-based pick-up points in August 2020, to assess access to COVID-19 information, available resources, and perceived personal and facility preparedness.

We completed interviews with 112 clinic staff (49 in April-May 2020, 63 in August 2020) and 24 pick-up point staff. Most clinic staff were healthcare providers (e.g., nurses, medical officers) or ancillary providers (e.g. counselors), while pick-up point staff were mainly pharmacists and dispensing clerks. Respondents primarily perceived increased need for prevention procedures and supplies (59%) as a challenge to their work in April-May, and COVID-19 infection risk (48%) in August. By August 2020, nearly all clinic staff reported access to resources (94%) and space (100%) to screen patients for COVID-19, while significantly fewer pick-up point staff reported access to these tools (54%, p<0.001). In August 2020, compared to clinic staff, pick-up point staff reported significantly lower rates of access to information to perform work duties during the COVID-19 pandemic (67% vs 94%, p=0.003), perceived facility preparedness to work with patients with COVID-19 (54% vs 81%, p=0.016), and access to necessary protective equipment (50% vs 89%, p <0.001).

Our results suggest that staff working in out-of-facility, community-based sites participating in decentralized HIV care programs do not feel as prepared to work with patients during the COVID-19 pandemic nor have access to the necessary supplies to carry out this work safely, compared to clinic-based counterparts. While further study is needed, our results highlight that if differentiated service delivery is to fulfill its potential to ensure continuity of care for people living with HIV during the COVID-19 pandemic, staff at all program levels and sites must be appropriately supported and prepared to deliver care safely to their patients.