“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, RoC’s 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 LT’s 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 LT’s 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. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved by the University of Washington Institutional Review Board (STUDY00013936) and the National Health Sciences Research Committee of Malawi (# 2968). All participants provided written informed consent. All participants were compensated with K10310.00 (approximately 10 USD) for their time. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data cannot be shared publicly because of privacy concerns among people living with HIV at this clinic who may be identified by findings of the focus group discussions. Data are available from the institutional review board at the University of Washington (contact via Jane Edelson (jedelson{at}uw.edu))) for researchers who meet the criteria for access to confidential data.