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: Introduction: In 2014, the South African government adopted a differentiated service delivery (DSD) model in its “National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs)” (AGL) to strengthen the HIV care cascade. We describe the barriers and facilitators of the AGL implementation as experienced by various stakeholders in eight intervention and control sites across four districts. Methods: Embedded within a cluster‐randomized evaluation of the AGL, we conducted 48 in‐depth interviews (IDIs) with healthcare providers, 16 IDIs with Department of Health and implementing partners and 24 focus group discussions (FGDs) with three HIV patient groups: new, stable and those not stable on treatment or not adhering to care. IDIs were conducted from August 2016 to August 2017; FGDs were conducted in January to February 2017. Content analysis was guided by the Consolidated Framework for Implementation Research. Findings were triangulated among respondent types to elicit barriers and facilitators to implementation. Results: New HIV patients found counselling helpful but intervention respondents reported sub‐optimal counselling and privacy concerns as barriers to initiation. Providers felt insufficiently trained for this intervention and were confused by the simultaneous rollout of the Universal Test and Treat strategy. For stable patients, repeat prescription collection strategies (RPCS) were generally well received. Patients and providers concurred that RPCS reduced congestion and waiting times at clinics. There was confusion though, among providers and implementers, around implementation of RPCS interventions. For patients not stable on treatment, enhanced counselling and tracing patients lost‐to‐follow‐up were perceived as beneficial to adherence behaviours but faced logistical challenges. All providers faced difficulties accessing data and identifying patients in need of tracing. Congestion at clinics and staff attitude were perceived as barriers preventing patients returning to care. Conclusions: Implementation of DSD models at scale is complex but this evaluation identified several positive aspects of AGL implementation. The positive perception of RPCS interventions and challenges managing patients not stable on treatment aligned with results from the larger evaluation. While some implementation challenges may resolve with experience, ensuring providers and implementers have the necessary training, tools and resources to operationalize AGL effectively is critical to the overall success of South Africa’s HIV control strategy., Introduction South Africa has the largest HIV treatment programme in the world, with 4.7 million public sector patients on treatment and a target of 6.1 million patients by end December [...]

: Introduction: In response to suboptimal adherence and retention, South Africa’s National Department of Health developed and implemented National Adherence Guidelines for Chronic Diseases. We evaluated the effect of a package of adherence interventions beginning in January 2016 and report on the impact of Fast‐Track Treatment Initiation Counselling (FTIC) on ART initiation, adherence and retention. Methods: We conducted a cluster‐randomized mixed‐methods evaluation in 4 provinces at 12 intervention sites which implemented FTIC and 12 control facilities providing standard of care. Follow‐up was by passive surveillance using clinical records. We included data on subjects eligible for FTIC between 08 Jan 2016 and 07 December 2016. We adjusted for pre‐intervention differences using difference‐in‐differences (DiD) analyses controlling for site‐level clustering. Results: We enrolled 362 intervention and 368 control arm patients. Thirty‐day ART initiation was 83% in the intervention and 82% in the control arm (RD 0.5%; 95% CI: −5.0% to 6.0%). After adjusting for baseline ART initiation differences and covariates using DiD we found a 6% increase in ART initiation associated with FTIC (RD 6.3%; 95% CI: −0.6% to 13.3%). We found a small decrease in viral suppression within 18 months (RD −2.8%; 95% CI: −9.8% to 4.2%) with no difference after adjustment (RD: −1.9%; 95% CI: −9.1% to 5.4%) or when considering only those with a viral load recorded (84% intervention vs. 86% control). We found reduced crude 6‐month retention in intervention sites (RD −7.2%; 95% CI: −14.0% to −0.4%). However, differences attenuated by 12 months (RD: −3.6%; 95% CI: −11.1% to 3.9%). Qualitative data showed FTIC counselling was perceived as beneficial by patients and providers. Conclusions: We saw a short‐term ART‐initiation benefit to FTIC (particularly in districts where initiation prior to intervention was lower), with no reductions but also no improvement in longer‐term retention and viral suppression. This may be due to lack of fidelity to implementation and delivery of those components that support retention and adherence. FTIC must continue to be implemented alongside other interventions to achieve the 90‐90‐90 cascade and fidelity to post‐initiation counselling sessions must be monitored to determine impact on longer‐term outcomes. Understanding the cost‐benefit and role of FTIC may then be warranted., INTRODUCTION Extensive data from sub‐Saharan Africa since large‐scale antiretroviral therapy (ART) rollout began shows suboptimal retention in HIV care. A particular point of concern is the period between treatment eligibility [...]

: Introduction: With limited funds available, meeting global health targets requires countries to both mobilize and prioritize their health spending. Within this context, countries have recognized the importance of allocating funds for HIV as efficiently as possible to maximize impact. Over the past six years, the governments of 23 countries in Africa, Asia, Eastern Europe and Latin America have used the Optima HIV tool to estimate the optimal allocation of HIV resources. Methods: Each study commenced with a request by the national government for technical assistance in conducting an HIV allocative efficiency study using Optima HIV. Each study team validated the required data, calibrated the Optima HIV epidemic model to produce HIV epidemic projections, agreed on cost functions for interventions, and used the model to calculate the optimal allocation of available funds to best address national strategic plan targets. From a review and analysis of these 23 country studies, we extract common themes around the optimal allocation of HIV funding in different epidemiological contexts. Results and discussion: The optimal distribution of HIV resources depends on the amount of funding available and the characteristics of each country's epidemic, response and targets. Universally, the modelling results indicated that scaling up treatment coverage is an efficient use of resources. There is scope for efficiency gains by targeting the HIV response towards the populations and geographical regions where HIV incidence is highest. Across a range of countries, the model results indicate that a more efficient allocation of HIV resources could reduce cumulative new HIV infections by an average of 18% over the years to 2020 and 25% over the years to 2030, along with an approximately 25% reduction in deaths for both timelines. However, in most countries this would still not be sufficient to meet the targets of the national strategic plan, with modelling results indicating that budget increases of up to 185% would be required. Conclusions: Greater epidemiological impact would be possible through better targeting of existing resources, but additional resources would still be required to meet targets. Allocative efficiency models have proven valuable in improving the HIV planning and budgeting process., Introduction If decisions on the allocation of health resources were guided by the principals of health economics alone, funds would be allocated in ways intended to lead to the greatest [...]

: Introduction: In 2014, city leaders from around the world endorsed the Paris Declaration on Fast‐Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS. The City of Johannesburg – one of South Africa's metropolitan municipalities and also a health district – has over 600,000 people living with HIV (PLHIV), more than any other city worldwide. We estimate what it would take in terms of programmatic targets and costs for the City of Johannesburg to meet the Fast‐Track targets, and demonstrate the impact that this would have. Methods: We applied the Optima HIV epidemic and resource allocation model to demographic, epidemiological and behavioural data on 26 sub‐populations in Johannesburg. We used data on programme costs and coverage to produce baseline projections. We calculated how many people must be diagnosed, put onto treatment and maintained with viral suppression to achieve the 2020 and 2030 targets. We also estimated how treatment needs – and therefore fiscal commitments – could be reduced if the treatment targets are combined with primary HIV prevention interventions (voluntary medical male circumcision (VMMC), an expanded condom programme, and comprehensive packages for female sex workers (FSW) and young females). Results: If current programmatic coverage were maintained, Johannesburg could expect 303,000 new infections and 96,000 AIDS‐related deaths between 2017 and 2030 and 769,000 PLHIV by 2030. Achieving the Fast‐Track targets would require an additional 135,000 diagnoses and 232,000 people on treatment by 2020 (an increase in around 80% over 2016 treatment numbers), but would avert 176,000 infections and 56,500 deaths by 2030. Assuming stable ART unit costs, this would require ZAR 29 billion (USD 2.15 billion) in cumulative treatment investments over the 14 years to 2030. Plausible scale‐ups of other proven interventions (VMMC, condom distribution and FSW strategies) could yield additional reductions in new infections (between 4 and 15%), and in overall treatment investment needs. Scaling up VMMC in line with national targets is found to be cost‐effective in the medium term. Conclusions: The scale‐up in testing and treatment programmes over this decade has been rapid, but these efforts must be doubled to reach 2020 targets. Strategic investments in proven interventions will help Johannesburg achieve the treatment targets and be on track to end AIDS by 2030., Introduction In 2014, city leaders from around the world endorsed the Paris Declaration on Fast‐Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS. The Fast‐Track [...]

Introduction: International investment in the response to HIV and AIDS has plateaued and its future level is uncertain. With many countries committed to ending the epidemic, it is essential to allocate available resources efficiently over different response periods to maximize impact. The objective of this study is to propose a technique to determine the optimal allocation of funds over time across a set of HIV programmes to achieve desirable health outcomes. Methods: We developed a technique to determine the optimal time‐varying allocation of funds (1) when the future annual HIV budget is pre‐defined and (2) when the total budget over a period is pre‐defined, but the year‐on‐year budget is to be optimally determined. We use this methodology with Optima, an HIV transmission model that uses non‐linear relationships between programme spending and associated programmatic outcomes to quantify the expected epidemiological impact of spending. We apply these methods to data collected from Zambia to determine the optimal distribution of resources to fund the right programmes, for the right people, at the right time. Results and discussion: Considering realistic implementation and ethical constraints, we estimate that the optimal time‐varying redistribution of the 2014 Zambian HIV budget between 2015 and 2025 will lead to a 7.6% (7.3% to 7.8%) decrease in cumulative new HIV infections compared with a baseline scenario where programme allocations remain at 2014 levels. This compares to a 5.1% (4.6% to 5.6%) reduction in new infections using an optimal allocation with constant programme spending that recommends unrealistic programmatic changes. Contrasting priorities for programme funding arise when assessing outcomes for a five‐year funding period over 5‐, 10‐ and 20‐year time horizons. Conclusions: Countries increasingly face the need to do more with the resources available. The methodology presented here can aid decision‐makers in planning as to when to expand or contract programmes and to which coverage levels to maximize impact., Introduction Despite ambitious targets to end the HIV epidemic, international investment in the global HIV response has plateaued in recent years [1,2]. At the same time, countries are increasingly expected [...]