Institute of HIV Research and Innovation, Bangkok, Thailand.
Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.
J Int AIDS Soc. 2021 Apr;24(4):e25693. doi: 10.1002/jia2.25693.
Differentiated service delivery (DSD) for antiretroviral therapy (ART) maintenance embodies the client-centred approach to tailor services to support people living with HIV in adhering to treatment and achieving viral suppression. We aimed to assess the preferences for HIV care and attitudes towards DSD for ART maintenance among ART clients and providers at healthcare facilities in Thailand.
A cross-sectional study using self-administered questionnaires was conducted in September-November 2018 at five healthcare facilities in four high HIV burden provinces in Thailand. Eligible participants who were ART clients aged ≥18 years and ART providers were recruited by consecutive sampling. Descriptive statistics were used to summarize demographic characteristics, preferences for HIV services and expectations and concerns towards DSD for ART maintenance.
Five hundred clients and 52 providers completed the questionnaires. Their median ages (interquartile range; IQR) were 38.6 (29.8 to 45.5) and 37.3 (27.3 to 45.1); 48.5% and 78.9% were females, 16.8% and 1.9% were men who have sex with men, and 2.4% and 7.7% were transgender women, respectively. Most clients and providers agreed that ART maintenance tasks, including ART refill, viral load testing, HIV/sexually transmitted infection monitoring, and psychosocial support should be provided at ART clinics (85.2% to 90.8% vs. 76.9% to 84.6%), by physicians (77.0% to 94.6% vs. 71.2% to 100.0%), every three months (26.7% to 40.8% vs. 17.3% to 55.8%) or six months (33.0% to 56.7% vs. 28.9% to 80.8%). Clients agreed that DSD would encourage their autonomy (84.9%) and empower responsibility for their health (87.7%). Some clients and providers disagreed that DSD would lead to poor ART retention (54.0% vs. 40.4%), increased loss to follow-up (52.5% vs. 42.3%), and delayed detection of treatment failure (48.3% vs. 44.2%), whereas 31.4% to 50.0% of providers were unsure about these expectations and concerns.
Physician-led, facility-based clinical consultation visit spacing in combination with multi-month ART refill was identified as one promising DSD model in Thailand. However, low preference for decentralization and task shifting may prove challenging to implement other models, especially since many providers were unsure about DSD benefits. This calls for local implementation studies to prove feasibility and governmental and social support to legitimize and normalize DSD in order to gain acceptance among clients and providers.
抗逆转录病毒疗法 (ART) 维持的差异化服务提供体现了以患者为中心的方法，旨在根据服务来支持艾滋病毒感染者坚持治疗并实现病毒抑制。我们旨在评估艾滋病毒护理的偏好以及泰国医疗机构内接受 ART 治疗的患者和提供者对 ART 维持差异化服务提供的态度。
2018 年 9 月至 11 月，在泰国四个高艾滋病毒负担省份的五家医疗机构中，采用横断面研究方法，使用自我管理问卷进行了研究。通过连续抽样，招募了年龄≥18 岁的 ART 患者和 ART 提供者。使用描述性统计来总结人口统计学特征、对艾滋病毒服务的偏好以及对 ART 维持差异化服务提供的期望和顾虑。
500 名患者和 52 名提供者完成了问卷。他们的中位年龄（四分位数范围；IQR）分别为 38.6（29.8 至 45.5）和 37.3（27.3 至 45.1）；48.5%和 78.9%为女性，16.8%和 1.9%为男男性行为者，2.4%和 7.7%为跨性别女性，分别。大多数患者和提供者都同意 ART 维持任务，包括 ART 续药、病毒载量检测、艾滋病毒/性传播感染监测和心理社会支持，应该在 ART 诊所提供（85.2% 至 90.8% 与 76.9% 至 84.6%），由医生提供（77.0% 至 94.6% 与 71.2% 至 100.0%），每三个月（26.7% 至 40.8% 与 17.3% 至 55.8%）或每六个月（33.0% 至 56.7% 与 28.9% 至 80.8%）。患者同意差异化服务提供将鼓励他们的自主权（84.9%）和增强对自身健康的责任感（87.7%）。一些患者和提供者不同意差异化服务提供会导致 ART 保留率下降（54.0% 与 40.4%）、失访增加（52.5% 与 42.3%）和治疗失败的检测延迟（48.3% 与 44.2%），而 31.4% 至 50.0%的提供者对这些期望和顾虑不确定。
在泰国，以医生为主导、以医疗机构为基础的临床咨询就诊间隔时间，结合多每月 ART 续药，被确定为一种有前途的差异化服务提供模式。然而，对权力下放和任务转移的低偏好可能对实施其他模式构成挑战，尤其是因为许多提供者对差异化服务提供的好处不确定。这需要进行当地的实施研究来证明可行性，以及需要政府和社会的支持来使差异化服务提供合法化和正常化，从而在患者和提供者中获得认可。
