Government to Government Model for HIV Service Delivery - An Approach for Country and Program Ownership in Four Provinces of Zambia.

INTRODUCTION: Beginning in fiscal year (FY) 2019, the U.S. Centers for Disease Control and Prevention in Zambia transitioned from non-governmental organizations to a government to government provincial health office service delivery model in four provinces in Zambia. We reviewed programmatic and financial data during and after this transition to assess outcomes of service delivery and financial investment through a government-led approach. METHODS: Programmatic performance using U.S. President's Emergency Plan for AIDS Relief's (PEPFAR) Monitoring, Evaluation, and Reporting and expenditure reporting data were used to assess changes over the period of transition. Data were reviewed across six FYs from October 2018-September 2019 (FY19) through October 2023-September 2024 (FY24) in four provinces. Programmatic and expenditure performance indicators were analysed across time. RESULTS: From FY19 to FY24, the number of people living with HIV (PLHIV) on antiretroviral therapy (ART) across the four provinces increased from 520,628 to 680,781 (31%). Viral load coverage and suppression in the transition provinces increased from 345,849/472,554 to 592,399/672403 (15%) and 313,384/345,849 to 578,832/592,399 (7%), respectively. Annual PEPFAR financial investments for care and treatment activities (in 2019 US dollars) increased by $12.7 million (25%) from $38.3 million in FY19 to $51.0 million in FY21, as the amount invested in direct service delivery increased concurrently with investments to implementing partners. From FY21 to FY24, spending declined by $21.1 million (41%), while the total number of PLHIV on ART increased. The amount spent per PLHIV on ART decreased by from $79 in FY21 to $44 in FY24 (44%). CONCLUSIONS: The government-led model in Zambia shows a path forward to achieving HIV program success, reductions in costs, and expanded government ownership of the HIV program.