Quality of care in a differentiated HIV service delivery intervention in Tanzania: A mixed methods study

Background: Differentiated service delivery (DSD) offers benefits to people living with HIV (improved access, peer support), and the health system (clinic decongestion, efficient service delivery). ART clubs, 15-30 clients who usually meet within the community, are one of the most common DSD options. However, evidence about the quality of care (QoC) delivered in DSD is still limited. Materials and Methods: We conducted a concurrent triangulation mixed methods study as part of the Test & Treat project in northwest Tanzania. We surveyed QoC among stable clients and health care workers (HCW) comparing between clinics and clubs. The Donabedian framework structured the analysis into three levels of assessment: structure (staff, equipment, supplies, venue), processes (time-spent, screenings, information, HCW-attitude), and outcomes (viral load, CD4 count, self-worth, health-status). Results: We surveyed 629 clients (40% in club) and conducted eight focus group discussions, while 24 HCW (25% in club) were surveyed and 22 individual interviews were conducted. Quantitative results revealed that in terms of structure, clubs fared better than clinics except for perceived adequacy of service delivery venue (94.4% vs 50.0%, p=0.013). For processes, time spent receiving care was significantly more in clinics than clubs (119.9 vs 49.9 minutes, p=<0.001). Regarding outcomes, the proportion of clients with recent viral load <50 copies/ml was higher in clinics than clubs (100% vs 94.4%, p=