Perspectives of healthcare providers on differentiated service delivery of long-acting cabotegravir and rilpivirine in clinics and community settings in England: findings from the ILANA non-randomised implementation study

Technical Summary: Perspectives of Healthcare Providers on Differentiated Service Delivery of Long-Acting Cabotegravir and Rilpivirine

Problem Statement
The introduction of long-acting injectable Cabotegravir and Rilpivirine (CAB+RPV) for HIV treatment represents a significant shift from daily oral regimens, requiring two-monthly appointments and rigorous adherence monitoring. While this offers patient benefits, it creates logistical challenges for HIV services historically structured around oral treatments. Specifically, the increased frequency of appointments and monitoring places pressure on clinic staffing and physical space. Furthermore, equitable uptake and retention may be hindered by varying clinic capacities, particularly for patients facing barriers to accessing care. Differentiated Service Delivery (DSD)—adapting the "who, where, when, and what" of service delivery—has been proposed as a solution to mitigate clinic pressure and improve accessibility. However, prior implementation research on community-based delivery of CAB+RPV has been limited to the US, Spain, and Australia, with a scarcity of data regarding provider perspectives in the UK context.

Methodology
The ILANA (Implementing Long-Acting Novel Antiretrovirals) study was a 12-month, mixed-methods, non-randomised implementation study conducted across six sites in England (London, Liverpool, and Brighton). The study involved 114 people living with HIV receiving CAB+RPV.

• Settings: Deliveries occurred in standard HIV clinics and three types of community settings: home visits (n=3 sites), HIV support organisations (n=2 sites), and a community sexual health clinic (n=1 site).
• Participants: The study focused on the perspectives of 25 Healthcare Providers (HCPs) involved in the administration and implementation of the treatment.
• Data Collection:
  • Quantitative: Longitudinal surveys were administered to HCPs at baseline, month 4 (clinic only), month 8 (community only), and month 12 (both). Surveys measured feasibility, acceptability, and appropriateness using validated instruments (FIM, AIM, IAM) on a 5-point scale.
  • Qualitative: Semi-structured interviews were conducted with a sub-sample of HCPs at baseline and month 12 (with community-specific interviews at month 8). Thematic analysis was performed using inductive and deductive coding informed by the Consolidated Framework for Implementation Research (CFIR).
• Design: The study was co-designed with a community advisory board and a co-author living with HIV.

Key Results

• Quantitative Findings:
  • High Scores: Both clinic and community HCPs reported high mean scores (≥4 out of 5) for feasibility, acceptability, and appropriateness across all timepoints.
  • Trends: Clinic HCPs showed improvement in scores over time. Conversely, community HCPs experienced a slight decline in acceptability and appropriateness scores between month 8 and month 12, though scores remained generally high.
  • Demographics: 68% of respondents were nurses, and 68% administered injections.
• Qualitative Findings:
  • Ownership and Decision-Making: Feasibility and acceptability were enhanced when HCPs felt a sense of ownership over the implementation process and were involved in decision-making. Lack of early collaboration or unclear rationales for community delivery reduced enthusiasm.
  • Resource and Equity Tensions: While CAB+RPV was viewed as clinically valuable, its implementation was constrained by limited resources (space, staff). HCPs noted that capacity pressures sometimes led to restricting discussions about the treatment to specific patients, raising concerns about equity and informed choice.
  • Operational Processes: Successful implementation relied on rigorous Standard Operating Procedures (SOPs), clear documentation, and flexibility (e.g., adaptable appointment times and injection sites).
  • Community Context: Home delivery was resource-intensive and often reserved for complex cases. Community settings (e.g., support groups) offered benefits like reduced stigma and peer support but faced challenges regarding professional standards, infection control, and low patient uptake due to privacy concerns.

Key Contributions
This paper provides the first mixed-methods evaluation of differentiated service delivery for CAB+RPV in the UK, specifically capturing the longitudinal perspectives of healthcare providers.

• It quantifies the feasibility, acceptability, and appropriateness of community-based delivery, demonstrating that while generally high, these metrics are sensitive to implementation dynamics.
• It identifies specific implementation barriers, including the tension between innovation and sustainability, the critical role of staff "ownership" in change management, and the logistical complexities of maintaining clinical standards in non-clinical environments.
• It highlights that patient need must be central to DSD decision-making to justify resource-intensive models like home visits.

Significance and Claims
The authors claim that the study demonstrates that delivering CAB+RPV in both clinic and community settings is largely feasible, acceptable, and appropriate for healthcare providers in England. However, the paper maintains a modest stance regarding scalability. It argues that while DSD can mitigate clinic pressure, current community models (particularly home visits and outreach) are resource-intensive and may not be sustainable without additional funding or structural changes.

The study concludes that successful implementation requires:

1. Patient-Centricity: Decisions on community delivery must be driven by genuine patient need rather than just operational convenience.
2. Process Rigor: Establishing flexible, safe, and efficient operational processes is essential.
3. Equity: Providers must ensure that capacity constraints do not lead to the withholding of information about new treatments from patients who might benefit, thereby exacerbating health inequities.

The paper does not propose new experimental applications but rather offers evidence-based guidance for policymakers and practitioners considering the rollout of long-acting injectable HIV treatments within the UK's publicly funded health system.