Background: In Zambia, growing numbers of people on ART and health system constraints has spurred differentiated service delivery (DSD). Nested within a mixed methods study on DSD in three provinces in Zambia, we compared anticipated and lived experiences of patients and health care workers (HCWs) prior to and after six months of implementation of urban adherence groups (UAG). The acceptability, feasibility and appropriateness of UAGs, which consist of a group of 30 patients who collect ART at a facility-based meeting held every 2-3 months during off hours, has not been previously studied in Zambia.
Methods: At baseline, we conducted 34 focus group discussions (FGDs) with patients, family members, and HCWs and 26 in-depth interviews (IDIs) with government officials and local leaders. At mid-line evaluation, we conducted 15 FGDs with professional HCWs and patients and, 18 IDIs with lay and professional HCWs. Audio transcripts were translated, transcribed and uploaded to Nvivo QSR?. Using framework analysis, major themes from both evaluations were compared by type of respondent and exposure to UAGs.
Results: Prior to implementation, working patients found the off-hours drug collections times highly acceptable while HCWs considered them unacceptable given current workloads and clinic space. Both patients and HCWs raised concerns regarding the big group size which could expose patients to stigma and unintentional disclosure. HCWs expressed concerns about physical safety, record keeping, security of stored drugs and working off-hours. After six months of implementation, both patients and HCWs found UAGs acceptable albeit with concerns about staff shortage, compensation for HCWs working off-hours and ARV storage space. Contrary to expectations, patients found that UAGs reduced HIV-related stigma and created group support. There were no reported cases of theft and physical harm. On the contrary, documentation and records were described as well-kept and updated.
Conclusions: Most pre-implementation concerns were not reported at mid-line demonstrating the importance of mitigating foreseeable challenges. Implementing UAGs can result in reduced HIV-related stigma, freed-up time for patients and potentially decongest day-time clinics. To effectively implement UAGs, health services must be re-organised by increasing UAG-specific staffing and, adapting clinic operations to meet off hours and ARV storage requirements.

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