Client and provider preferences for HIV care: Implications for implementing differentiated service delivery in Thailand

Abstract

Introduction: 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. Methods: 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. Results: 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. Conclusions: 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.

Differentiated service delivery for HIV treatment models in Thailand: A cross‐sectional assessment of real‐world implementation and uptake

“…Approximately 85% of clients received ART from facilitybased models, which were led by healthcare professionals and with MMD available. This finding coincides with our previous study, which found high preference for facility-based models over community-based models among ART clients in Thailand [17]. Only 3.6% and 2.7% of our clients received ART at the pharmacist-led pickup centers and KP-led CBOs, respectively.…”

“…Studies in Ghana and Zimbabwe suggest that the opportunity for comprehensive care and lower risk of inadvertent disclosure of HIV status due to the distance from home drove the preference for facility-based models among some PLHIV [18,24]. Thai people tend to trust and prefer receiving health services from healthcare professionals, particularly physicians, as they are perceived as more knowledgeable in a paternalistic healthcare system [17,25]. Some PLHIV in Thailand also feared social discrimination from disclosing their HIV status [26], which might make them want the sense of privacy and confidentiality of facility-based models over community-based models as well as individual models over group models.…”

Evaluation of HIV treatment outcomes with reduced frequency of clinical encounters and antiretroviral treatment refills: A systematic review and meta-analysis

“…While we found overall little difference in clinical outcomes for reduced visit frequency, there are other potential benefits of reduced visits, including decongestion of health facilities, reduced provider workload, prioritization of care for new or clinically unstable PLWH, and reduced transmission of COVID-19 in health centers [ 5 , 13 , 41 – 44 ]. Reducing visit frequency has been reported to be one of the easiest DSD models to implement and aligns strongly with the care preferences of PLWH by reducing the economic costs of attending frequent appointments, reducing stigma, and allowing PLWH to normalize HIV [ 3 , 4 , 10 , 11 , 45 , 46 ]. HIV services, however, need to remain flexible enough to accommodate return to facilities for those who opt back into standard care or when clinical requirements change [ 27 ].…”

Provider preferences for delivery of HIV care coordination services: results from a discrete choice experiment

“…Our research adds to a growing body of knowledge around patient‐ and provider‐stated preferences for HIV prevention, counselling, testing, care and treatment [ 19 , 20 , 21 , 31 , 32 , 33 , 34 , 35 ]. Many studies focus on the clinical aspects of HIV care and treatment (viral load testing location and frequency, ART refill frequency, etc.…”

“…In this study, providers endorsed the provision of support services, such as medication and appointment reminders; these are similar to our findings, though providers in our study preferred DOT over medication reminders alone, and accompanying clients or arranging transportation for clients over appointment reminders alone. Another study examined provider preferences for differentiated service delivery and ART maintenance services in Thailand, finding that providers endorsed longer ART refill visit spacing and the decentralization of ART maintenance services, as well as psychosocial support [ 32 ]. These findings align with our own; though many of these studies varied the frequency of services, such as viral load testing and ART refills, none explicitly varied the intensity of the service, and none included items specifically related to DOT.…”