When ART is not a magic bullet: Tailored care for vulnerable people living with hiv in the era of treat-all in Shinyanga, Tanzania.

Community health workers (CHWs) play a crucial role in supporting retention in HIV care in Tanzania under the World Health Organization's Treat-All policy. While the WHO promotes the differentiated service delivery (DSD) model for stable clients, not all people living with HIV (PLHIV) can achieve sustained viral suppression independently. Using ethnographic case studies of one CHW and three vulnerable clients in Shinyanga, Tanzania (2022-2023), we examine how CHWs adapt patient-centred care in the current era of Treat-All. The findings demonstrate that treatment adherence for highly vulnerable groups, particularly children and older adults, relies on collaborative care involving families, neighbours, religious actors, non-governmental organizations, and health providers. CHWs' flexibility and community embeddedness enable them to identify individuals at risk of disengagement and mobilize these care networks. Increased formalization of CHWs within health systems, though beneficial, risks undermining their embeddedness and limiting their capacity to detect need and respond effectively. The study highlights the need for continued financial support for community-based care systems that recognize and support CHWs' relational and moral labour.SGD 3: Good health and well-being.SGD 17: Partnerships for the goals.