"They provide the right kind of support." A qualitative study of preferences for differentiated service delivery location among recipients of antiretroviral therapy at Lighthouse Trust in Lilongwe, Malawi

Differentiated service delivery (DSD) models for antiretroviral therapy (ART) allow stable recipients of care (RoC) to receive multi-month ART drug refills and complete rapid reviews in community sites. As DSD options expand across sub-Saharan Africa, RoCs preferences and perspectives on community-versus clinic-based care models warrants attention. We describe the factors that influence RoC choice of ART delivery approaches at Lighthouse Trust (LT) clinics and community-based DSD sites in Lilongwe, Malawi. We conducted eight focus group discussions (FGDs) among LT RoC in the Nurse-led Community-based ART Program (NCAP) (n=4) and in clinic settings (n=4) to explore opinions, preferences, and perceptions about ART service delivery. FGDs were conducted and recorded in Chichewa and then translated and transcribed into English for analysis. Data was analyzed using thematic analysis and findings discussed with the LT and NCAP teams to jointly reflect on the findings. Sixty-three participants took part in the qualitative study. Results were largely similar across care locations. In both NCAP and clinic FGDs, RoC appreciated the convenience of integrating their appointment visits at their chosen care location into their daily lives, though some RoC traveled far to access LTs high quality of care. RoC were satisfied with the quality of the care they received at their location of choice. Privacy protection was an important consideration for choosing care models. At LT clinics, RoC highlighted the importance of physical separation between LTs HIV-specific service site and other service sites. In NCAP, RoC expressed that their choice of care model was reinforced by the sense of mutual support that they received through the peer support model. At LT, RoC in both clinic and NCAP care models expressed satisfaction with their chosen care model and preferred that choice over alternative options and locations. Overall, LT RoC appreciated the quality of care, the respectful provider-to-patient interactions, and the attention to privacy at community and clinic sites. These findings suggest continued emphasis on offering choices to RoC on where and how they receive ART delivery approaches may support ongoing engagement in care.