尼日利亚贝努埃州基于社区的抗逆转录病毒疗法（CBART）方案对关键人群的实际评估。

Realist evaluation of a community-based antiretroviral therapy (CBART) programme for key populations in Benue State in Nigeria.

机构信息

Institute of Tropical Medicine, Antwerp, Belgium.

APIN Public Health Initiatives, Abuja, Nigeria.

出版信息

BMC Infect Dis. 2024 Aug 31;24(1):892. doi: 10.1186/s12879-024-09808-w.

DOI:10.1186/s12879-024-09808-w

PMID:39217280

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11366157/

Abstract

BACKGROUND

World Health Organization recommended community-based ART (CBART) approaches to improve access to antiretroviral treatment (ART) and treatment outcomes among key populations living with (KPLHIV). Key populations (KP) are female sex workers, men who have sex with men, persons who inject drugs, and transgender people. How CBART for KP (KP-CBART) worked and why, for whom and in what circumstances it worked within KP communities or at community sites, are yet to be described. The aim of this study is to describe the different KP-CBART approaches or models in Nigeria, identifying the context conditions and mechanisms that are likely to produce the desired outcomes.

METHOD

Building on our previous study eliciting an initial programme theory for KP-CBART, we used a multiple case design and cross-case analysis to evaluate 3 KP-CBART approaches, namely: One Stop Shop clinic; community drop-in centre; and outreach venue. Between 2021 and 2023, we conducted a retrospective cohort study, 99 indepth interviews and 5 focused group discussions with various actors. Using realist evaluation, we synthesised context-mechanism-outcome configurations (CMOCs) and developed programme theory for each of the cases and an overall theory.

RESULT

The analysis showed the central importance of decentralizing ART service delivery to a safe place within the community for KPLHIV. The provision of ART in a KP friendly environment triggered a feeling of safety and trust in the healthcare workers among KPLHIV, resulting in KP-CBART acceptance and improved ART uptake, medication adherence and retention on ART. KP community engagement in ART delivery, peer support through support group meetings, and linkages with KP-led organizations improved self-efficacy, fostered solidarity and a sense of belonging among KP. These resources encouraged and motivated clients to engage with the KP-CBART model. However, fear of disclosure of HIV and KP status, and lack of trust between KP groups, demotivated and discouraged KPLHIV from initiating ART and continuing their treatment in KP-CBART.

CONCLUSION

To optimise access to ART and treatment outcomes for KPLHIV, policy makers and health practitioners should ensure the provision of a safe place for ART service delivery that can be trusted by the clients and the KP communities.

摘要

背景

世界卫生组织推荐以社区为基础的抗逆转录病毒治疗（CBART）方法，以改善关键人群（包括女同性恋者、男同性恋者、双性恋者、跨性别者、性工作者和注射吸毒者）获得抗逆转录病毒治疗（ART）和治疗效果的机会。关键人群（KP）是指女同性恋者、男同性恋者、双性恋者、跨性别者、性工作者和注射吸毒者。KP 人群中的 CBART（KP-CBART）是如何运作的，为什么会运作，以及在 KP 社区或社区场所为谁和在什么情况下运作，这些问题仍有待描述。本研究旨在描述尼日利亚不同的 KP-CBART 方法或模式，确定可能产生预期结果的背景条件和机制。

方法

基于我们之前关于 KP-CBART 的初步方案理论的研究，我们使用多案例设计和跨案例分析来评估 3 种 KP-CBART 方法，即一站式诊所、社区中途停留中心和外展场所。在 2021 年至 2023 年期间，我们对各种行为者进行了回顾性队列研究、99 次深入访谈和 5 次焦点小组讨论。使用现实主义评估，我们综合了背景-机制-结果配置（CMOC），并为每个案例和总体理论发展了方案理论。

结果

分析表明，将 ART 服务提供去中心化到社区内的安全场所对于 KP 中的 HIV 感染者至关重要。在 KP 友好的环境中提供 ART 服务，会在 HIV 感染者中产生对医护人员的安全感和信任感，从而促使 KP-CBART 被接受，并提高 ART 的接受率、药物依从性和 ART 治疗的保留率。KP 社区参与 ART 服务提供、通过支持小组会议提供同伴支持、以及与 KP 主导的组织建立联系，提高了 KP 的自我效能感，促进了团结和归属感。这些资源鼓励和激励客户参与 KP-CBART 模式。然而，对 HIV 和 KP 身份披露的恐惧，以及 KP 群体之间缺乏信任，使 HIV 感染者在开始 ART 和继续在 KP-CBART 中接受治疗方面感到气馁。