New York State Psychiatric Institute and Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, Gender, Sexuality and Health Area, Columbia University Irving Medical Center, New York, New York, United States of America.
ICAP at Columbia University, New York, NY, United States of America.
BMC Health Serv Res. 2023 May 31;23(1):563. doi: 10.1186/s12913-023-09549-7.
Multi-month dispensing (MMD) of antiretroviral therapy (ART) is an integral component of differentiated HIV service delivery for people living with HIV (PLHIV). Although many countries have scaled up ART dispensing to 3-month intervals, Ethiopia was the first African country to implement six-month dispensing (6-MMD) at scale, introducing its Appointment Spacing Model (ASM) for people doing well on ART in 2017. As of June 2021, 51.4% (n = 215,101) of PLHIV on ART aged ≥ 15 years had enrolled in ASM. Since little is known about the benefits and challenges of ASM perceived by Ethiopian clients and their healthcare workers (HCWs), we explored how the ASM was being implemented in Ethiopia's Oromia region in September 2019.
Using a parallel convergent mixed-methods study design, we conducted 6 focus groups with ASM-eligible enrolled clients, 6 with ASM-eligible non-enrolled clients, and 22 in-depth interviews with HCWs. Data were audio-recorded, transcribed and translated into English. We used thematic analysis, initially coding deductively, followed by inductive coding of themes that emerged from the data, and compared the perspectives of ASM-enrolled and non-enrolled clients and their HCWs.
Participants enrolled in ASM and HCWs perceived client-level ASM benefits to include time and cost-savings, fewer work disruptions, reduced stigma due to fewer clinic visits, better medication adherence and improved overall health. Perceived health system-level benefits included improved quality of care, decongested facilities, reduced provider workloads, and improved record-keeping. Although non-enrolled participants anticipated many of the same benefits, their reasons for non-enrollment included medication storage challenges, concerns over less frequent health monitoring, and increased stress due to the large quantities of medicines dispensed. Enrolled participants and HCWs identified similar challenges, including client misunderstandings about ASM and initial ART stock-outs.
ASM with 6-MMD was perceived to have marked benefits for clients and health systems. Clients enrolled in the ASM and their HCWs had positive experiences with the model, including perceived improvements in efficiency, quality and convenience of HIV treatment services. The concerns of non-ASM enrolled participants suggest the need for enhanced client education about the model and more discreet and efficiently packaged ART and highlight that ASM is not ideal for all clients.
抗逆转录病毒疗法（ART）的多（月）配药是为艾滋病毒感染者（PLHIV）提供差异化 HIV 服务的一个组成部分。尽管许多国家已经将 ART 配药延长至 3 个月的间隔，但埃塞俄比亚是第一个在大规模实施 6 个月配药（6-MMD）的非洲国家，它于 2017 年为在 ART 上表现良好的人推出了预约间隔模型（ASM）。截至 2021 年 6 月，51.4%（n=215101）年龄≥15 岁的接受 ART 治疗的 PLHIV 已注册 ASM。由于人们对埃塞俄比亚客户及其医疗保健工作者（HCW）感知到的 ASM 的好处和挑战知之甚少，我们在 2019 年 9 月探索了 ASM 在埃塞俄比亚奥罗米亚地区的实施情况。
使用平行收敛混合方法研究设计，我们对符合 ASM 条件的注册客户进行了 6 次焦点小组讨论，对符合 ASM 条件的未注册客户进行了 6 次焦点小组讨论，对 HCW 进行了 22 次深入访谈。数据被录音、转录并翻译成英文。我们使用主题分析，最初进行演绎式编码，然后对数据中出现的主题进行归纳式编码，并比较了 ASM 注册客户和未注册客户及其 HCW 的观点。
注册 ASM 的参与者和 HCW 认为客户层面 ASM 的好处包括节省时间和成本、减少工作中断、因就诊次数减少而减少耻辱感、更好地遵守药物治疗和改善整体健康。感知到的卫生系统层面的好处包括改善护理质量、设施不拥挤、减少提供者工作量以及改善记录保存。尽管未注册的参与者预计会有许多相同的好处，但他们不注册的原因包括药物储存困难、对较少的健康监测的担忧，以及因分发的药物数量增加而增加的压力。注册参与者和 HCW 发现了类似的挑战，包括客户对 ASM 的误解和初始 ART 库存不足。
6-MMD 的 ASM 被认为对客户和卫生系统有显著的好处。注册 ASM 的客户及其 HCW 对该模型有积极的体验，包括认为艾滋病毒治疗服务的效率、质量和便利性有所提高。未注册 ASM 的参与者的担忧表明，需要加强对该模型的客户教育，并需要更谨慎和有效地包装 ART，并突出表明 ASM 并不适合所有客户。
