Sustaining differentiated service delivery for HIV care through community adherence clubs in Tanzania

With the expansion of antiretroviral therapy (ART) under the Treat-All policy, innovative approaches are needed to sustain large-scale treatment programs. Differentiated service delivery (DSD) models, particularly community adherence clubs, have emerged as a promising strategy. Evidence suggests that such clubs are viable and cost-effective in resource-limited settings with fragile health systems. However, this evidence is mostly limited to demonstration programs, which lack information about their sustainability or their integration into health systems. This ethnographic study was conducted as part of the Test & Treat Project in Tanzania and assessed the viability of the DSD model through clubs, analyzing their contextual benefits, challenges, and sustainability. It found that adherence clubs were particularly beneficial for women and older people in rural areas, while younger people and men were less inclined to join due to concerns about confidentiality and stigma. Members adapted clubs to fit their needs and priorities, addressing both medical and social concerns. Clubs reduced congestion in health facilities and improved community-based care; however, their project-based implementation posed challenges for adoption and sustainability post-project. These findings underscore the importance of implementing sustainability strategies, such as integrating health systems, to sustain DSD successes in settings that heavily rely on external donor funding.