Published in PLOS One on 2026-07-31, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Noa Gluskinos, Caroline Maposhere, Ushehwedu Kufakurinani, Godfrey Hove, Kathy McCarty, David Katzenstein, Anat Rosenthal, Richard Makurumidze, Lara Vojnov
Source: PLOS One • DOI 10.1371/journal.pone.0354747
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Decentralization of antiretroviral therapy (ART) brought treatment to millions of people in Sub-Saharan Africa. However, the implications of such decentralization are still not fully understood.
The study included 60 semi-structured interviews with community leaders, healthcare providers, patients, and community members served by a rural mission hospital in Zimbabwe, conducted in January-March 2019. Interviews were transcribed and translated into English and coded using an iterative codebook. Coded extracts were grouped into themes and categories, systematically using QDA Miner qualitative analysis software.
The study reveals that treatment-for-all policies and decentralization of ART have indeed improved access to care (as experienced by the study participants). However, the study shows that these policies also had unintended negative consequences. Stigma and complex social relations significantly affect the practices and experiences of ART outreach care, for both patients and healthcare providers, and may hamper attempts to reduce stigma as well as increase physical and social barriers to accessing ART.
The study’s results highlight the need to understand the consequences of the decentralization of HIV care, as well as the barriers and facilitators associated with ART outreach in order to improve quality of care and provide true accessibility to HIV care for all.
Introduction
The broad introduction of antiretroviral therapy (ART) in low-income countries brought urgently needed treatment to millions of people, especially in Sub-Saharan Africa. No less important, efforts to achieve the 90-90-90 targets (defined as having 90% of people living with human immunodeficiency virus/HIV knowing their status; 90% of those aware of their HIV-positive status receiving treatment; and 90% of those receiving treatment achieving suppressed viral loads) [1], and later amended to 95-95-95 targets, required focused efforts to reach an ever growing number of people. One strategy to expand access to HIV care was decentralization—shifting services from central hospitals to local clinics. The aim of this approach was to reduce barriers by providing ART closer to patients’ homes [2].
It was assumed that the introduction of the “Treat All” policy (i.e., immediate treatment of all people living with HIV regardless of their CD4 + cell count) in a decentralized system would remove existing barriers to care, reduce HIV-related stigma, and increase knowledge about HIV and ART so that patients could benefit from ART’s widespread accessibility [3,4]. However, studies have shown that these goals were not necessarily met [5,6]. Therefore, questions about the effects of the “Treat All” policy, and the extent to which it has indeed improved knowledge about ART, reduced stigma, and expanded access to care, remain to some extent unanswered. Using semi-structured interviews with community members and healthcare workers in rural Zimbabwe, we examined the effect of the decentralization of HIV care and the impact of outreach programs on patients and providers. Based on the findings of the study, we argue that treatment-for-all policies and the decentralization of ART have indeed improved access to care (as experienced by the study participants), but that they have also had unintended negative consequences that could hamper attempts to reduce stigma as well as increase physical and social barriers to accessing ART. Understanding these consequences, and the barriers and facilitators to care that are associated with ART outreach, is an important step toward improving quality of and access to care.
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider hospital systems desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Noa Gluskinos, Caroline Maposhere, Ushehwedu Kufakurinani, Godfrey Hove, Kathy McCarty, David Katzenstein, Anat Rosenthal, Richard Makurumidze, Lara Vojnov. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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