{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,2]],"date-time":"2025-08-02T18:43:19Z","timestamp":1754160199737,"version":"3.41.2"},"reference-count":27,"publisher":"Wiley","issue":"7","license":[{"start":{"date-parts":[[2025,6,28]],"date-time":"2025-06-28T00:00:00Z","timestamp":1751068800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["OPP1192640","INV\u2010037138"],"award-info":[{"award-number":["OPP1192640","INV\u2010037138"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J Int AIDS Soc."],"published-print":{"date-parts":[[2025,7]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Introduction<\/jats:title><jats:p>Differentiated service delivery (DSD) models for antiretroviral treatment (ART) have been scaled up in many settings in sub\u2010Saharan Africa to improve client\u2010centred care and increase service delivery efficiency. However, given the multitude of models of care currently available, identifying cost\u2010effective combinations of DSD models that maximize benefits and minimize costs remains critical for guiding their expansion.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We developed an Excel\u2010based mathematical model using retrospective retention and viral suppression data from a national cohort of ART clients (\u226515 years) in Zambia between January 2018 and March 2022 stratified by age, sex, setting (urban\/rural) and model of ART delivery. Outcomes (viral suppression and retention in care), provider costs and costs to clients were estimated from the cohort and published data. The base case reflects the outcomes observed in 2022 for all DSD models for each population sub\u2010group. For different combinations of nine DSD models and over 1\u2010year time horizon from the provider perspective, we evaluated the incremental cost\u2010effectiveness ratio (ICER) per additional client virally suppressed compared to the 2022 base case. Deterministic sensitivity analyses were conducted on key input parameters.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Among 125 scenarios evaluated, six were on the cost\u2010effectiveness frontier: (1) 6\u2010month dispensing (6MMD)\u2010only; (2) 6MMD and adherence groups (AGs); (3) AGs\u2010only; (4) fast track refills (FTRs) and AGs; (5) FTRs\u2010only; and 6) AGs and home ART delivery. 6MMD\u2010only was cost\u2010saving compared to the base case, increasing retention by 1.2% (95% CI: 0.7\u22121.8), viral suppression by 1.6% (95% CI: 1.0\u22122.7) and reducing client costs by 12.0% (95% CI: 10.8\u221212.4). The next cost\u2010effective scenarios, 6MMD + AGs and AGs\u2010only, cost $245 per additional person virally suppressed, increased viral suppression by 2.8% (95% CI: 2.2\u22123.3) and 4.0% (95% CI: 3.5\u22124.0) and increased client costs by 20.1% (95% CI: 9.5\u221228.1) and 52.3% (95% CI: 29.868.7), respectively. ART cost and laboratory test costs were the most influential parameters on provider costs and the ICERs.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Mathematical modelling using existing data can identify cost\u2010effective DSD model mixes while ensuring all client sub\u2010populations are considered. In Zambia, scaling up 6MMD to all eligible clients is likely cost\u2010saving, with further health gains achievable by targeting sub\u2010populations with selected DSD models.<\/jats:p><\/jats:sec>","DOI":"10.1002\/jia2.70003","type":"journal-article","created":{"date-parts":[[2025,6,28]],"date-time":"2025-06-28T03:04:03Z","timestamp":1751079843000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cost and effectiveness of differentiated ART service delivery strategies in Zambia: a modelling analysis using routine data"],"prefix":"10.1002","volume":"28","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7951-7333","authenticated-orcid":false,"given":"Nkgomeleng A.","family":"Lekodeba","sequence":"first","affiliation":[{"name":"Health Economics and Epidemiology Research Office Faculty of Health Sciences University of the Witwatersrand  Johannesburg South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6560-2964","authenticated-orcid":false,"given":"Sydney","family":"Rosen","sequence":"additional","affiliation":[{"name":"Health Economics and Epidemiology Research Office Faculty of Health Sciences University of the Witwatersrand  Johannesburg South Africa"},{"name":"Department of Global Health Boston University School of Public Health  Boston Massachusetts USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bevis","family":"Phiri","sequence":"additional","affiliation":[{"name":"Clinton Health Access Initiative  Lusaka Zambia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sithabiso D.","family":"Masuku","sequence":"additional","affiliation":[{"name":"Health Economics and Epidemiology Research Office Faculty of Health Sciences University of the Witwatersrand  Johannesburg South Africa"},{"name":"SCHARR, Sheffield Centre for Health and Related Research Division of Population Health, School of Medicine and Population Health University of Sheffield  Sheffield England"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2595-1913","authenticated-orcid":false,"given":"Caroline","family":"Govathson","sequence":"additional","affiliation":[{"name":"Health Economics and Epidemiology Research Office Faculty of Health Sciences University of the Witwatersrand  Johannesburg South Africa"},{"name":"Department of Global Health Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam  Amsterdam Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aniset","family":"Kamanga","sequence":"additional","affiliation":[{"name":"Clinton Health Access Initiative  Lusaka Zambia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Prudence","family":"Haimbe","sequence":"additional","affiliation":[{"name":"Clinton Health Access Initiative  Lusaka Zambia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hilda","family":"Shakwelele","sequence":"additional","affiliation":[{"name":"Clinton Health Access Initiative  Lusaka Zambia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Muya","family":"Mwansa","sequence":"additional","affiliation":[{"name":"Ministry of Health  Lusaka Zambia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Priscilla","family":"Lumano\u2010Mulenga","sequence":"additional","affiliation":[{"name":"Ministry of Health  Lusaka Zambia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Amy N.","family":"Huber","sequence":"additional","affiliation":[{"name":"Health Economics and Epidemiology Research Office Faculty of Health Sciences University of the Witwatersrand  Johannesburg South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9199-8333","authenticated-orcid":false,"given":"Sophie J. S.","family":"Pascoe","sequence":"additional","affiliation":[{"name":"Health Economics and Epidemiology Research Office Faculty of Health Sciences University of the Witwatersrand  Johannesburg South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2354-4580","authenticated-orcid":false,"given":"Lise","family":"Jamieson","sequence":"additional","affiliation":[{"name":"Health Economics and Epidemiology Research Office Faculty of Health Sciences University of the Witwatersrand  Johannesburg South Africa"},{"name":"South African Centre for Epidemiological Modelling and Analysis (SACEMA) Stellenbosch University  Stellenbosch South Africa"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4682-4999","authenticated-orcid":false,"given":"Brooke E.","family":"Nichols","sequence":"additional","affiliation":[{"name":"Health Economics and Epidemiology Research Office Faculty of Health Sciences University of the Witwatersrand  Johannesburg South Africa"},{"name":"Department of Global Health Boston University School of Public Health  Boston Massachusetts USA"},{"name":"Department of Global Health Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam  Amsterdam Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2025,6,28]]},"reference":[{"doi-asserted-by":"publisher","key":"e_1_2_11_2_1","DOI":"10.7448\/IAS.20.5.22024"},{"doi-asserted-by":"publisher","key":"e_1_2_11_3_1","DOI":"10.1002\/jia2.25640"},{"volume-title":"Updated recommendations on service delivery for the treatment and care of people living with HIV","year":"2021","author":"World Health Organisation","key":"e_1_2_11_4_1"},{"volume-title":"National Guidelines for Antiretroviral Therapy","year":"2019","author":"Ministry of Health and Social Services","key":"e_1_2_11_5_1"},{"volume-title":"Zambia Differentiated Service Delivery Framework Ministry of Health Zambia Differentiated Service Delivery Framework 2018 Zambia Differentiated Service Delivery Framework 2018","year":"2018","author":"Ministry of Health","key":"e_1_2_11_6_1"},{"volume-title":"Zambia Guidelines for Treatment and Prevention of HIV Infection","year":"2020","author":"Ministry of Health Zambia","key":"e_1_2_11_7_1"},{"volume-title":"Differentiated Service Delivery (DSD) Framework","year":"2022","author":"Ministry of Health Zambia","key":"e_1_2_11_8_1"},{"doi-asserted-by":"publisher","key":"e_1_2_11_9_1","DOI":"10.9745\/GHSP\u2010D\u201020\u201000532"},{"doi-asserted-by":"publisher","key":"e_1_2_11_10_1","DOI":"10.1371\/journal.pone.0196498"},{"doi-asserted-by":"publisher","key":"e_1_2_11_11_1","DOI":"10.12688\/gatesopenres.13458.2"},{"doi-asserted-by":"publisher","key":"e_1_2_11_12_1","DOI":"10.1371\/journal.pone.0280748"},{"doi-asserted-by":"publisher","key":"e_1_2_11_13_1","DOI":"10.1186\/s12913\u2010023\u201009114\u20102"},{"doi-asserted-by":"publisher","key":"e_1_2_11_14_1","DOI":"10.1002\/jia2.26275"},{"doi-asserted-by":"publisher","key":"e_1_2_11_15_1","DOI":"10.1016\/j.ssaho.2023.100399"},{"doi-asserted-by":"publisher","key":"e_1_2_11_16_1","DOI":"10.1136\/bmjopen\u20102019\u2010030428"},{"doi-asserted-by":"publisher","key":"e_1_2_11_17_1","DOI":"10.1186\/s12913\u2010022\u201008629\u20104"},{"unstructured":"Joint United Nations Programme on HIV\/AIDS.Global\u2010HIV\/AIDS Statistics.Zambia:Country fact sheet;2023.https:\/\/www.unaids.org\/en\/regionscountries\/countries\/zambia. 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