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Impact of HIV Treatment Differentiated Service Delivery on HIV Clinic Attendance in Nigeria

Abstract

HIV infection remains an important public health concern in Nigeria, requiring sustained engagement with healthcare services to support treatment adherence, viral suppression, prevention of complications, and improved quality of life. Regular clinic attendance is an important component of HIV care because it enables patients to receive antiretroviral medicines, clinical monitoring, adherence counselling, laboratory services, and other supportive interventions. However, conventional facility-based HIV care may create challenges for some patients, including long waiting times, transportation costs, distance to healthcare facilities, frequent clinic visits, stigma, work-related constraints, and other social and economic barriers. HIV treatment differentiated service delivery (DSD) provides an alternative approach that adapts the delivery of HIV treatment and care to patients' needs through models such as multi-month dispensing, community-based medicine distribution, appointment spacing, fast-track services, adherence clubs, and other patient-centred approaches. These models may reduce the burden associated with routine facility visits and improve patients' engagement with HIV treatment services. Against this background, this study investigates the impact of HIV treatment differentiated service delivery on HIV clinic attendance in Nigeria. The study will be anchored on the Social Ecological Model, Andersen's Behavioral Model of Health Services Use, and the Donabedian Model of Healthcare Quality. The Social Ecological Model emphasizes the interaction between individual, interpersonal, community, healthcare-system, and broader environmental factors in influencing HIV service utilization. Andersen's Behavioral Model explains healthcare utilization through predisposing, enabling, and need factors, with differentiated service delivery serving as an enabling mechanism for reducing barriers to HIV care. The Donabedian Model explains healthcare quality through structure, process, and outcome, with HIV treatment DSD representing an important service-delivery process and clinic attendance serving as a measurable outcome. Collectively, these theoretical perspectives provide a suitable framework for explaining how differentiated HIV treatment services may influence clinic attendance among people living with HIV in Nigeria. The study will adopt a quantitative quasi-experimental or analytical cohort research design. The study population will comprise adults receiving HIV treatment in selected public and private healthcare facilities and community-based HIV treatment programmes in Nigeria. A multistage sampling technique will be used to select states, local government areas, healthcare facilities, HIV treatment clinics, community service points, and eligible patients. HIV treatment differentiated service delivery will be assessed using indicators such as enrolment in DSD models, multi-month dispensing, appointment spacing, community-based medicine distribution, fast-track services, adherence clubs, frequency of medicine collection, community refill points, adherence counselling, patient follow-up, service accessibility, waiting time, and patient choice of service-delivery model. HIV clinic attendance will be assessed using indicators such as scheduled appointment attendance, number of clinic visits completed, missed appointments, delayed appointments, timely medicine collection, continuity of treatment visits, retention in HIV care, and loss to follow-up. Where relevant, clinical records such as viral load monitoring and treatment refill records may be reviewed as supporting indicators of continuity of HIV care. Data will be collected using structured questionnaires, HIV clinic registers, appointment records, pharmacy or dispensing records, DSD enrolment records, patient medical records, community refill records, and programme monitoring documents. Descriptive statistics will be used to summarize patients' demographic and clinical characteristics, DSD participation, service utilization, and clinic attendance patterns. Inferential statistical techniques, including chi-square tests, t-tests, correlation analysis, and logistic or multiple regression analysis where appropriate, will be used to determine the impact of differentiated service delivery on HIV clinic attendance. Where a quasi-experimental design is adopted, clinic attendance before and after enrolment in DSD may be compared, or attendance among DSD participants may be compared with that of patients receiving conventional facility-based HIV services. Diagnostic tests will also be conducted to assess the reliability, validity, and robustness of the findings. The study is expected to find that HIV treatment differentiated service delivery has a significant positive impact on HIV clinic attendance in Nigeria. Patients enrolled in appropriate DSD models are expected to demonstrate improved attendance, fewer missed appointments, more consistent medicine collection, and better retention in HIV care than patients receiving conventional frequent facility-based services. Multi-month dispensing and appointment spacing may reduce transportation costs, waiting time, and the frequency of facility visits, while community-based medicine distribution and fast-track services may improve convenience and accessibility. Patient-centred service models may also reduce some barriers associated with work schedules, geographical distance, and concerns about repeated visits to HIV treatment facilities. However, inadequate medicine supplies, limited availability of community service points, poor programme coordination, stigma, confidentiality concerns, staff shortages, and inconsistent implementation of DSD models may reduce their effectiveness. The study therefore expects accessible, patient-centred, adequately resourced, and consistently implemented differentiated HIV treatment services to contribute significantly to improved clinic attendance and retention in HIV care in Nigeria. The study is expected to contribute to the literature on HIV differentiated service delivery, HIV clinic attendance, HIV treatment retention, antiretroviral therapy, patient-centred HIV care, community-based HIV services, treatment adherence, and public health in Nigeria. The findings will provide useful information to the Federal Ministry of Health and Social Welfare, National Agency for the Control of AIDS, National Primary Health Care Development Agency, state ministries of health, HIV treatment facilities, healthcare providers, HIV programme managers, community-based organizations, development partners, and policymakers regarding strategies for improving continuity of HIV treatment. The study will also provide evidence-based recommendations for expanding differentiated service delivery models, strengthening multi-month dispensing, increasing access to community-based medicine distribution, improving appointment scheduling and patient follow-up, ensuring uninterrupted antiretroviral medicine supplies, strengthening healthcare worker training, protecting patient confidentiality, and adapting HIV treatment services to patients' needs to improve clinic attendance and retention in HIV care across Nigeria.

Keywords: HIV treatment, differentiated service delivery, HIV clinic attendance, antiretroviral therapy, HIV care, treatment retention, multi-month dispensing, community-based HIV services, patient-centred care, Nigeria, public health.