Community-based HIV care shows promise in Zambia, but costs and distance limit its reach

Zambia has spent more than two decades building one of the largest antiretroviral therapy programs in sub-Saharan Africa, yet the everyday logistics of delivering lifelong medication to hundreds of thousands of people remain a formidable challenge. A new study published in BMC Public Health examines how the country is trying to ease that burden through Differentiated Service Delivery, or DSD, models—flexible, patient-centered ways of distributing antiretroviral therapy that move care away from the crowded one-size-fits-all clinic queue. Using the RE-AIM framework, a widely used implementation science tool, researchers from the University of Zambia and the Ministry of Health traced how these models performed across selected health facilities in ten districts, capturing both the perspectives of people living with HIV who receive care through them and the program implementers who run them at every level, from provincial officials to frontline health workers.

The logic behind differentiated service delivery is straightforward but powerful. Traditional antiretroviral therapy programs require patients to visit a health facility frequently, often monthly, for refills and check-ups. For stable clients, this is inefficient for the health system and burdensome for the patient, particularly in rural areas where a single clinic visit can consume an entire day and significant transport money. DSD models reorganize care around the needs of distinct patient groups, allowing clinically stable clients to receive their medication through less intensive channels, such as community distribution points, while reserving intensive facility-based care for those who need closer monitoring. The approach was established with the explicit aim of improving patient outcomes while simultaneously increasing the efficiency of the health system itself.

To evaluate how these models are actually working on the ground, the research team adopted a case study design. They conducted in-depth interviews with individuals receiving antiretroviral therapy through a DSD model, and key informant interviews with program implementers across multiple administrative levels. All interviews were guided by semi-structured interview guides, audio recorded, and transcribed verbatim. Participants were selected through purposive sampling, a technique that deliberately identifies information-rich cases—in this case, people with direct, varied experience of the models. The team then applied thematic analysis, organizing the findings according to the five dimensions of the RE-AIM framework: Reach, Effectiveness, Adoption, Implementation, and Maintenance. This structure allowed the researchers to assess not just whether the models work, but who they serve, how they are adopted, and whether they can endure.

On the question of reach, the study delivered a sobering but important finding: the overall reach of the DSD models is shaped significantly by cost and distance to the health facility. In other words, the very barriers that differentiated care is designed to reduce can also determine who manages to access it in the first place. For patients living far from distribution points or unable to afford transport, the theoretical benefits of a more flexible model may remain out of reach. This finding underscores a persistent tension in implementation science: an intervention that looks equitable on paper can reproduce existing inequalities in access unless geography and economics are explicitly engineered into its design.

Effectiveness, by contrast, emerged as a clear strength. The researchers found that the DSD models improved adherence to antiretroviral therapy, a critical outcome given that consistent medication-taking suppresses viral load and prevents both disease progression and onward transmission. The models also produced an unexpected systems benefit: they allowed health facility staff to plan client visits systematically. Rather than contending with unpredictable daily surges of patients, facilities could anticipate demand, allocate staff more rationally, and devote scarce clinician time to complex cases. In this sense, differentiated service delivery functions as a kind of demand-management technology for the health system, redistributing routine tasks so that human resources can be deployed where they matter most.

Adoption—the willingness of facilities and communities to take up the models—was strengthened by deliberate local adaptations. The study documented modifications that facilitated adoption, including the use of information, education, and communication materials to explain the models to clients and communities, and the active participation of traditional and community leaders. These local champions play a crucial role in contexts where trust in formal health institutions may be uneven and where stigma around HIV remains a barrier to engagement. By involving leaders who command community credibility, program implementers helped legitimize the new care pathways and encourage uptake among people who might otherwise have stayed away from clinic-based services.

The implementation dimension of the framework asked whether the models were delivered as intended, and here the findings were encouraging. The DSD models were successfully implemented as planned, supported by regular monitoring and ongoing training. This fidelity between design and execution is notable in large public health programs, where drift between policy and practice is common. Yet the study also surfaced a forward-looking concern: implementers recommended capacity building and expansion of human resources to maintain the models over time. Without a pipeline of trained staff and adequate workforce numbers, the systematic visit planning and monitoring that make the models work could erode, threatening the durability of the gains.

One of the most striking recommendations from the study concerns inclusion. The researchers proposed that future models should be created with a specific focus on meeting the needs of people with disabilities. This is a dimension of differentiated HIV care that is often overlooked, and it highlights how reach and equity must be considered together. A model that reduces visits for the general population of stable clients may inadvertently exclude clients who face physical, sensory, or cognitive barriers to accessing community distribution points or who require accommodations that the current designs do not anticipate. Building disability-inclusive features into the architecture of DSD models from the outset, rather than retrofitting them later, would be a significant step toward genuinely universal access to therapy.

Taken together, the RE-AIM analysis suggests that differentiated service delivery in Zambia is a promising strategy for improving the delivery of antiretroviral services, and the authors conclude that the findings highlight the importance of rolling out these models to cater to more people throughout the country. But the study is equally clear-eyed about what national scale-up will require. The models will only extend their reach if the financial and geographic barriers identified by patients are addressed, if community engagement through local leaders and communication materials continues, if the health workforce grows to sustain systematic planning and monitoring, and if future designs explicitly incorporate the needs of people with disabilities. In a country where so many people depend on lifelong therapy, the lesson of this research is that the next phase of the HIV response depends as much on implementation science—on understanding how programs actually behave in the world—as on the medicines themselves.

Subject of Research: Implementation of Differentiated Service Delivery models for antiretroviral therapy in Zambian health facilities, evaluated using the RE-AIM framework

Article Title: Implementation of DSD models in selected health facilities in Zambia: a RE-AIM framework analysis

Article References: Mulavu, M., Mulawa, M. J., Sitali, D., Jacobs, C., Zulu, J. M., Hamoonga, T. E., Chavula, M. P., Zyambo, C., Matenga, T. F. L., Kaonga, P., Musukuma, M., Sampa, M., Phiri, H., Hikabasa, H., & Mweemba, O. (2026). Implementation of DSD models in selected health facilities in Zambia: a RE-AIM framework analysis. BMC Public Health. https://doi.org/10.1186/s12889-026-28789-w

Image Credits: AI Generated

DOI: 10.1186/s12889-026-28789-w

Keywords: HIV, antiretroviral therapy, Differentiated Service Delivery, Zambia, RE-AIM framework, implementation science, public health, health systems, adherence, health facilities, community health, task shifting