Population-level coverage and correlates of enrollment in community-based antiretroviral therapy (ART) refill models following differentiated service delivery scale-up in Africa: a multi-country study

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Community-based antiretroviral therapy (ART) distribution is a promising strategy to increase HIV treatment accessibility in Africa, yet population-level coverage and correlates of enrollment are understudied. We pooled data from seven Population-based HIV Impact Assessment surveys (2020–2023) and used survey-weighted multivariable logistic regression with jackknife variance estimation to identify socio-demographic and clinical correlates of enrollment in community, relative to facility-based, ART distribution models. Across countries, 11,629 virally suppressed (<1000 RNA copies/ml) persons on ART for >12 months (mean age: 42.1 years, 67.0% female) self-reported their assigned ART refill model, 2.9% of whom received ART from a community-based pickup point (range: 0.5% in Mozambique to 7.6% in Zimbabwe). Correlates of enrollment in a community-based refill model included rural residence (adjusted odds ratio [adjOR] = 2.24, 95% confidence interval [CI]:1.20–4.21), past-year mobility (adjOR=1.56, 95%CI: 1.05–2.31), ART dispensing intervals of >6 months (adjOR=2.36, 95%CI: 1.11–5.02), and transportation-related barriers to facility-based HIV care (adjOR=1.43, 95%CI: 1.01–2.03). Among virally suppressed males, superior virologic control at the <200 copies/ml (adjOR=7.12, 95%CI: 1.59–31.97) and <400 copies/ml (adjOR=6.08, 95%CI: 1.34–27.57) levels was observed among those enrolled in a community-based, relative to facility-based, ART distribution model. Findings affirm the potential of community-based refill models to reach populations susceptible to HIV care attrition, but coverage estimates remain low, indicating implementation barriers.