Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)‘s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perspectives on barriers to implementation of Differentiated ART service delivery in Uganda. We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context. Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Context: Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups. This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

中文翻译：

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了解乌干达在全国范围内扩大差异化ART交付的实施障碍。

自世界卫生组织（WHO）具有里程碑意义的2016年指南以来，尽管在多个国家/地区已在全国范围内推出了抗逆转录病毒疗法（ART）的差异化服务交付（DSD），但很少有研究评估实施后的结果。这项研究的目的是探讨患者和艾滋病毒服务管理者对乌干达实施差异化ART服务提供的障碍的看法。我们采用了定性的描述性设计，涉及124位参与者。在2019年4月至6月之间，我们对国家一级的HIV项目经理（n = 18），地区卫生团队负责人（n = 24），PEPFAR实施组织的代表（11），ART诊所负责人（23）进行了76次定性访谈。在六个目标明确的乌干达艾滋病毒高负担地区（坎帕拉，卢韦罗，瓦基索，姆巴莱，布兰迪（Budadiri）。在病例研究区中，与参加DSD模型的患者进行了六次焦点小组讨论（48名参与者）。在多层次分析框架的指导下，通过专题方法对数据进行了分析：卫生系统因素；社区因素；和上下文。我们的数据表明，在DSD实施中遇到了多个障碍。个人层面：据报导存在个性化的污名和害怕被以社区为基础的模型的稳定患者从健康机构中分离出来的瓶颈。据报道，社会经济状况会影响患者对DSD模型的选择。卫生系统：对卫生工作者的DSD交付和数月ART分配的供应链障碍的培训不足被认为是制约因素。患者认为当前对DSD模型的选择是提供者密集型的，而不是足够以患者为中心的。社区：社区水平的污名化以及对提供者的资金不足，无法完全实施社区吸毒点的运作被认为是局限性。背景：据报道，城市客户的实际住址经常发生变化，阻碍了旋转ART补充装取回病人组的运行。这是自2017年首次推广以来，对乌干达国家DSD实施情况的首次多方利益相关者评估。需要多层次的干预措施，以从需求方加快在乌干达进一步实施DSD（解决与艾滋病相关的污名，社区参与） ）和供应方尺寸（加强ART的供应链能力，