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Differentiated antiretroviral therapy (ART) delivery models, in which patients are provided with care relevant to their current status (e.g., newly initiating, stable on treatment, or unstable on treatment) has become an essential part of patient-centered health systems. In 2015, the South African government implemented Chronic Disease Adherence Guidelines (AGLs), which involved five interventions: Fast Track Initiation Counseling for newly initiating patients, Enhanced Adherence Counseling for patients with an unsuppressed viral load, Early Tracing of patients who miss visits, and Adherence Clubs (ACs) and Decentralized Medication Delivery (DMD) for stable patients. We evaluated two of these interventions in 24 South African facilities: ACs, in which patients meet in groups outside usual clinic procedures and receive medication; and DMD, in which patients pick up their medication outside usual pharmacy queues. We compared those participating in ACs or receiving DMD at intervention sites to those eligible for ACs or DMD at control sites. Outcomes were retention and sustained viral suppression (<400 copies/mL) 12 months after AC or DMD enrollment (or comparable time for controls). 12 facilities were randomly allocated to intervention and 12 to control arms in four provinces (Gauteng, North West, Limpopo, and KwaZulu Natal). We calculated adjusted risk differences (aRDs) with cluster adjustment using generalized estimating equations (GEEs) using difference in differences (DiD) with patients eligible for ACs/DMD prior to implementation (Jan 1, 2015) for comparison. For DMD, randomization was not preserved, and the analysis was treated as observational. For ACs, 275 intervention and 294 control patients were enrolled; 72% of patients were female, 61% were aged 30-49 years, and median CD4 count at ART initiation was 268 cells/μL. AC patients had higher 1-year retention (89.5% versus 81.6%, aRD: 8.3%; 95% CI: 1.1% to 15.6%) and comparable sustained 1-year viral suppression (<400 copies/mL any time ≤ 18 months) (80.0% versus 79.6%, aRD: 3.8%; 95% CI: -6.9% to 14.4%). Retention associations were apparently stronger for men than women (men RD: 13.1%, 95% CI: 0.3% to 23.5%; women RD: 6.0%, 95% CI: -0.9% to 12.9%). For DMD, 232 intervention and 346 control patients were enrolled; 71% of patients were female, 65% were aged 30-49 years, and median CD4 count at ART initiation was 270 cells/μL. DMD patients had apparently lower retention (81.5% versus 87.2%, aRD: -5.9%; 95% CI: -12.5% to 0.8%) and comparable viral suppression versus standard of care (77.2% versus 74.3%, aRD: -1.0%; 95% CI: -12.2% to 10.1%), though in both cases, our findings were imprecise. We also noted apparently increased viral suppression among men (RD: 11.1%; 95% CI: -3.4% to 25.5%). The main study limitations were missing data and lack of randomization in the DMD analysis. In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of community-based strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest clinics, comparable outcomes are a potential success. The cost of all five AGL interventions and possible effects on reducing clinic congestion should be investigated. NCT02536768.

Replacing conventional, facility-based HIV treatment with less intensive differentiated service delivery (DSD) models could benefit DSD clients and the health system, but its value depends on maintaining or improving clinical outcomes. We compared retention and viral suppression between antiretroviral therapy (ART) clients enrolled in DSD models to those eligible for but not enrolled in DSD models in South Africa. We applied a target trial emulation (TTE) methodology to data from South Africa's electronic medical record system (TIER.Net) for 24 public-sector health facilities across three provinces and estimated retention in care (attended facility visit within 12 months) and viral suppression (<400 copies/ml3) at 12, 24, and 36 months after follow-up start date, defined as DSD enrollment date for the intervention arm and the first trial enrollment period facility visit for the comparison arm. Clients were eligible for DSD models if they were ≥18 years old, on ART ≥12 months, and had two suppressed viral load (VL) measurements, per prevailing national guidelines. For the TTE, we designated eight 6-month target trial enrollment periods between 1 July 2017 and 1 July 2021. For each period, we estimated the risk differences for retention in care and viral suppression by comparing those enrolled in DSD models to those not enrolled, using a Poisson distribution with an identity link function. We report adjusted and unadjusted risk differences for clients enrolled in DSD models and for DSD-eligible clients not enrolled in a DSD model. Estimates were adjusted for age, sex, urban/rural facility setting, province, WHO stage at ART initiation, and years on ART at trial enrollment. 49,595 unique individuals were eligible for DSD enrollment over eight target trials, contributing to a total of 148,943 trial-clients, of whom 17% (25,775) were enrolled in DSD models. The pooled adjusted risk difference for retention in care between clients enrolled in DSD and those not enrolled in DSD was 3.2% (95% confidence interval (CI) [1.6%,4.7%]) at 12 months, 4.2% (95% CI [2.4%,6.0%]) at 24 months, and 4.4% (95% CI [2.0%,6.8%]) at 36 months. For viral suppression, the adjusted risk difference comparing DSD to non-DSD was estimated to be 1.4% (95% CI [-0.5%,3.2%]) at 12 months, 1.7% (95% CI [-0.5%,4.0%]) at 24 months, and 1.4% (95% CI [-0.6%,4.4%]) at 36 months. Results remained consistent across target trials. Clients who were younger, received care from a facility in an urban settings, or had less ART experience at trial enrollment had lower retention. Study limitations include reliance on routinely collected medical records and the likely presence of residual confounding. Clients enrolled in DSD models in South Africa had slightly better retention in care and similar viral suppression to those who were eligible for but not enrolled in DSD. With better or equivalent outcomes, DSD models can be assessed on the basis of non-clinic costs and benefits, such as changes in quality of care and resource utilization. Clinicaltrials.gov NCT04149782.

Introduction Differentiated service delivery (DSD) models for antiretroviral treatment (ART) for HIV are being scaled up in the expectation that they will better meet the needs of patients, improve the quality and efficiency of treatment delivery and reduce costs while maintaining at least equivalent clinical outcomes. We reviewed the recent literature on DSD models to describe what is known about clinical outcomes. Methods We conducted a rapid systematic review of peer‐reviewed publications in PubMed, Embase and the Web of Science and major international conference s that reported outcomes of DSD models for the provision of ART in sub‐Saharan Africa from January 1, 2016 to September 12, 2019. Sources reporting standard clinical HIV treatment metrics, primarily retention in care and viral load suppression, were reviewed and categorized by DSD model and source quality assessed. Results and discussion Twenty‐nine papers and s describing 37 DSD models and reporting 52 discrete outcomes met search inclusion criteria. Of the 37 models, 7 (19%) were facility‐based individual models, 12 (32%) out‐of‐facility‐based individual models, 5 (14%) client‐led groups and 13 (35%) healthcare worker‐led groups. Retention was reported for 29 (78%) of the models and viral suppression for 22 (59%). Where a comparison with conventional care was provided, retention in most DSD models was within 5% of that for conventional care; where no comparison was provided, retention generally exceeded 80% (range 47% to 100%). For viral suppression, all those with a comparison to conventional care reported a small increase in suppression in the DSD model; reported suppression exceeded 90% (range 77% to 98%) in 11/21 models. Analysis was limited by the extensive heterogeneity of study designs, outcomes, models and populations. Most sources did not provide comparisons with conventional care, and metrics for assessing outcomes varied widely and were in many cases poorly defined. Conclusions Existing evidence on the clinical outcomes of DSD models for HIV treatment in sub‐Saharan Africa is limited in both quantity and quality but suggests that retention in care and viral suppression are roughly equivalent to those in conventional models of care.

A growing number of people living with HIV (PLHIV) also have non-communicable diseases (NCDs). Shifting to an integrated delivery model may facilitate care-seeking and improve outcomes for people with a dual burden of HIV and NCDs. We describe the current state of integration of hypertension and diabetes care into HIV treatment in Malawi, South Africa and Zambia. We administered structured interviews to HIV treatment providers in 41 primary healthcare facilities to evaluate how NCD care is provided to PLHIV accessing antiretroviral therapy (ART). We defined integration as provision of NCD services within the HIV clinic. The potential degree of integration in HIV clinics ranged from not integrated at all (no NCD services) to fully integrated (all NCD services). We also surveyed a sample of ART clients about their access to integrated care. The degree of integration varied across the facilities and countries. All facilities in South Africa reported being fully integrated for HIV care and hypertension and diabetes, and most providers in South Africa identified no barriers to integration. Integration was much less complete in Malawi and Zambia, with most facilities offering hypertension and diabetes screening/diagnosis and support but limited treatment or disease monitoring services. Frequently cited barriers to integration in Malawi and Zambia were limited staff knowledge of integrated care provision and facility space constraints. ART clients' experience with integrated services mirrored provider responses. Over 90% of survey participants in South Africa reported HIV and non-HIV visit and medication collection alignment, compared to less than half in Malawi and Zambia. The level of integration of hypertension and diabetes care with HIV treatment varies widely across facilities in Malawi, South Africa, and Zambia, despite each country having national guidelines that promote integration. Interventions to increase integration must consider differences among facilities at baseline.

Introduction Global and national guidelines recommend the integration of care for HIV and other chronic conditions to improve individual and public health outcomes. South Africa's differentiated service delivery (DSD) models extend beyond HIV care, relying on pickup points that also distribute hypertension (HTN) medications. We assessed the alignment between antiretroviral treatment (ART) and HTN medication collection visits and dispensing intervals as an indicator of integration progress. Methods The AMBIT project conducted a SENTINEL survey across 18 public clinics in three South African districts between September 2022 and April 2023, enrolling adult clients ≥ 6 months on ART. We recruited up to 180 clients across each model of care: conventional care‐not DSD eligible (conventional‐not‐eligible); conventional care‐DSD eligible but not enrolled (conventional‐eligible); facility‐ (FAC‐PuP) and external (EX‐PuP) pickup points. Healthcare interaction data were extracted from paper and electronic sources for clients with a 12‐month observation period. We analysed both self‐reported alignment and actual visit data. We estimated the number and proportion of HTN visits aligned with ART dispensing. Log‐binomial regression estimated adjusted risk ratios (ARR) to assess the association with a higher visit burden (> 5 interactions). Results Of 724 enrolled, 644 (90%) client records were successfully linked (76% female; median age 42; 15% Conventional‐not‐eligible; 17% Conventional‐eligible; 18% FAC‐PuP; 28% EX‐PuP). Among these, 85 (13%) with HTN (81 self‐reported, 4 from medical records), self‐reported 94% and 95% aligned facility visits and medication pickups, respectively. Visit data was retrieved for self‐reported HTN diagnoses. Of 477 visits for HIV/HTN comorbid clients, 83% (395) dispensed both ART and HTN medication, and 97% had aligned dispensing durations (Conventional‐not‐eligible 97%, Conventional‐eligible 95%, FAC‐PuP 98%, EX‐PuP 100%). Comorbid clients had a similar visit burden to ART‐only clients (ARR 1.05, 95% CI: 0.80−1.39). FAC‐PuP (ARR 0.55, 95% CI: 0.40−0.78) and EX‐PuP (ARR 0.75, 95% CI: 0.57−0.98) clients were less likely than Conventional‐E clients to have high annual visit burden. Conclusions Aligning medication visits and dispensing for HIV and other chronic diseases marks an initial step towards integrated service delivery. Our results demonstrate achievable medication visit alignment without increased visit burden for comorbid clients and those in DSD models, suggesting that HIV‐HTN integration is feasible within DSD models, matching client preferences for comprehensive care.

When presenting projects in competitive design environments, how you say something is as important as what you’re actually saying. Projects are increasingly complex; designers are working from more sources and can struggle with how to harness this information and craft a meaningful and engaging story from it.Telling the Design Story: Effective and Engaging Communicationteaches designers how to craft cohesive and innovative presentations through storytelling. From the various stages of the creative process to the nuts and bolts of writing and speaking for impact, to creating visuals, Amy Huber provides a comprehensive approach for designers creating presentations for clients. Including chapter-by-chapter exercises, project briefs, and useful guides, this is an essential resource for students and practicing designers alike.

Many African countries have increased the dispensing duration of antiretroviral therapy (ART) from 3 months to 6 months for established HIV treatment clients. To assess South African healthcare providers' views on the benefits and challenges of the current maximum ART dispensing duration (3-month, 3MMD) and of potential 6-month dispensing (6MMD) to help inform South Africa about whether to move from 3MMD to 6MMD. We conducted a cross-sectional survey of healthcare providers at 24 primary healthcare clinics in South Africa from May to September 2024. We used descriptive analysis for quantitative data and analysed open-ended responses using conventional qualitative content analysis methods. A total of 182 providers were enrolled from four provinces (median age 44, 88% female). Most (>70%) respondents said that 3MMD offered multiple benefits for providers and patients, and most (64%) also said there were no challenges in implementing 3MMD. More than 80% of respondents across all cadres reported that they would be comfortable dispensing 6 months of ART at a time, believing that it would reduce the facility overcrowding, lighten staff workloads, and be advantageous to clients by decreasing their visit burden and travel costs. Two thirds (63%) of participating nurses, who provide the largest share of direct ART care, were also in favour of resuming 12-month scripting for ART; the remaining 37% expressed concerns about decreases in treatment adherence and clinical monitoring of clients. Most healthcare providers at primary healthcare clinics in South Africa are in favour of allowing 6-month dispensing and 12-month prescriptions as options for established ART clients.

Background Many countries in sub-Saharan Africa are rapidly scaling up “differentiated service delivery” (DSD) models for HIV treatment to improve the quality of care, increase access, reduce costs, and support the continued expansion and sustainability of antiretroviral therapy (ART) programs. Although there is some published evidence about the health outcomes of patients in DSD models, little is known about their impacts on healthcare providers’ job satisfaction, patients’ quality of life, costs to providers or patients, or how DSD models affect resource allocation at the facility level. Methods SENTINEL is a multi-year observational study that will collect detailed data about DSD models for ART delivery and related services from 12 healthcare facilities in Malawi, 24 in South Africa, and 12 in Zambia. The first round of SENTINEL included a patient survey, provider survey, provider time-and-motion observations, and facility resource use inventory. A survey of clients testing for HIV and a supplement to the facility resource use component to describe service delivery integration will be added for the second round. The patient survey will ask up to 10 patients enrolled in each DSD model at each study site about their experiences in HIV care and in DSD models, costs incurred seeking treatment, and preferences for HIV service delivery. The provider survey will ask up to 10 providers per site about the impact of DSD models on their positions and clinics. The time-and-motion component will directly observe the time use of a sample of providers implementing DSD models. Finally, the resource utilization component will collect facility-level data about DSD model availability and enrollment and the human and other resources needed to implement them. SENTINEL is planned to include four or more approximately annual rounds of data collection between 2021 and 2026. Discussion As national DSD programs for HIV treatment mature, it is important to understand how individual healthcare facilities are interpreting and implementing national guidelines and how healthcare workers and clients are adapting to new models of service delivery. SENTINEL will help policy makers and program managers understand the benefits and costs of differentiated service delivery and improve resource allocation going forward.

Telling the Design Story: Effective and Engaging Communications teaches designers to craft cohesive and innovative presentations through storytelling.

Many teaching in higher education whose fields rely heavily on processes using technology can be overwhelmed by the pace of developments, and, in turn, have difficulties identifying those competencies necessary for their students to have mastered. These educators may feel as though they are aiming at a moving target, and given the number of new platforms and communication tactics, this target could seem increasingly distant. One such field greatly impacted by rapidly developing technology is interior design, wherein practitioners are increasingly leveraging tactics that promise newfound fidelity, interoperability, and greater production speed. However, it is unclear how these advancements may influence the expectations for entry-level designers—and by extension—the curricula of design educators. The purpose of this research was to apply a Systems Thinking approach to determine technology’s influence on both the design process and the production of deliverables. Data was gathered from design practitioners surrounding the variety of software and technological applications used during four phases of the design process (e.g., schematic, design development, construction documents, and construction administration). To determine adoption trends, these responses were compared to previous data from Dyar and Huber (in: Sarawgi (ed) Interior design educators annual national council, Fort Worth, TX, Interior Design Educators Council, Chicago, 2015). Responses were analyzed with descriptive crosstabs and inferential statistics, including T-tests, Analysis of Variance, and posthoc Tukey’s Range Tests. The findings suggest that expectations for students, and consequently, their instructors, are evolving rapidly. While this study is rooted in interior design, its methodology and its implications may prove valuable to allied design fields.