Retention in HIV care and acceptability of an adolescent and youth focused community‑based differentiated service delivery model in Ethiopia: a comparative mixed‑methods study

Abstract

Adolescents and young people living with HIV (AYLHIV) aged 10–24 years continue to experience poorer outcomes across the HIV-care cascade than other age groups. Although differentiated service delivery models offer client-centered approaches to address structural and psychosocial barriers, evidence on adolescent and youth specific community-based models (AY- CDSDMs) in sub–Saharan Africa remains limited. We assessed the association between enrollment in AY-CDSDM and retention in HIV care and evaluated the model’s acceptability among AYLHIV in Ethiopia. We conducted a concurrent, comparative mixed-methods study in 20 purposively selected health facilities across eight high HIV burden regions of Ethiopia. Quantitative data were obtained through a retrospective review of medical records for 721 randomly selected AYLHIV aged 10–24 years who received HIV care between January 2024 and February 2025. We compared retention in care between those enrolled in AY-CDSDMs and those receiving conventional facility-based care. Multivariable logistic regression was used to identify factors associated with retention. Additionally, we conducted 54 key informant interviews and 11 focus group discussions to explore acceptability and implementation. Qualitative data were analyzed using inductive thematic analysis guided by the theoretical framework of acceptability. Among the 721 participants (mean age, 19 ± 3.4 years; 54% female), 359 (49.8%) were enrolled in AY-CDSDM and 362 (50.2%) received conventional facility-based care. Overall retention in care was 96.9% (95% CI: 96.5–97.3%). Retention was higher among AY-CDSDM participants (98.6%; 95% CI: 98.1–99.1%) than among those receiving conventional facility-based care (95.3%; 95% CI: 94.8–95.8%). Enrollment in AY-CDSDM was independently associated with higher odds of retention in care (AOR = 3.56; 95% CI: 1.20–10.58; p = 0.022). Qualitative findings indicated high acceptability of AY-CDSDM, highlighting perceived relevance and convenience, strengthened peer-support, reduced logistical and psychosocial barriers, and improved treatment-related confidence among participants. However, physical distance remained a minor barrier for a small subset of participants. Enrollment in AY-CDSDM was associated with higher retention in HIV care and demonstrated high acceptability among AYLHIV in Ethiopia. By addressing structural and psychosocial barriers through peer-led, community-based approaches, AY-CDSDM represents a promising and scalable strategy to optimize retention in HIV care in resource limited settings.