Optimizing the service delivery of PrEP for HIV prevention in Belgium

Project Details


Background and problem statement
Oral pre-exposure prophylaxis (PrEP) is a very safe and efficacious HIV prevention method [1]. Given the sub-optimal global uptake of PrEP, key priorities for future PrEP implementation include maximizing access and reaching those at substantial risk of HIV. In Belgium, publicly funded PrEP was approved by health authorities in June 2017. The delivery of PrEP care has been organized almost exclusively through a centralized system of 12 specialized and multidisciplinary HIV clinics (i.e. ‘HIV Reference Centers’). Studies suggests that the growing demand for PrEP could put a strain on this centralized system [2-3]. Scaling-up PrEP services calls for a sustainable approach that balances equitable access with the provision of high quality care. This will likely require adapting the current delivery model for PrEP, including exploring potential de-centralization strategies. However, it remains currently unclear what a de-centralized, client-centered and sustainable service delivery model for PrEP in Belgium could look like.

Research questions
The overall objective of this thesis is: “to understand how the service delivery of PrEP in Belgium can be organized to ensure it is responsive to users’ needs, while preserving quality of care and limiting the burden on the health system”. Specific research questions include: (RQ1) “How has PrEP service delivery been implemented globally and in Belgian HIV clinics?”; (RQ2) “What are current PrEP providers’ experiences, perceptions and attitudes related to quality of care for PrEP?"; (RQ3) “How do Flemish family physicians perceive their role in the service delivery of PrEP?”; and (RQ4) “What are users’ needs and preferences for receiving PrEP care in the future?”.

This thesis will have a observational, cross-sectional, mixed-methods design consisting of four components. First, to answer the first part of RQ1, a systematic scoping review of peer-reviewed and grey literature was performed to make an inventory of currently applied PrEP delivery models globally [6]. Then, to answer the second part of RQ1 and RQ2, we have set up a qualitative multiple case study of PrEP implementation in different Belgian HIV Reference Centers (HRCs). Study sites were selected through opportunity sampling, with 8 out of 12 HRCs who agreed to participate. Data collection activities at each site include: qualitative interviews with PrEP providers, semi-structured observations of delivery settings and clinical care processes, and review of documents relevant to understanding care practices and structure. Participants for the interviews are recruited through purposive sampling (e.g. a mix of medical, para-medical, auxiliary and supporting staff). We aim to include a minimum of 3 interviews per study site, with the option of including additional interviews based on the concept of ‘data saturation’, as per the iterative nature of qualitative social science research. For RQ3, we have conducted focus group discussions (FGDs) with family physicians practicing in Flanders [7]. We included 16 groups, with a mix in type of practice and urbanicity, to allow for adequate exploration and comparison across groups. Group discussions were held with a minimum of 4 and a maximum of 10 participants per group. Lastly, RQ4 will be addressed through a mixed-methods study. An online survey will be conducted among 250 current PrEP users, recruited via social media and PrEP-delivering HRCs. Through purposive sampling, based on the survey’s findings and specific answers to the questions, a sub-sample of 20 survey participants who provided consent to be contacted will be invited for an interview to focus more in-depth on experiences with PrEP care and their needs and care preferences for the future. All qualitative data in this thesis (verbatim transcripts, field notes and summaries) will be analyzed iteratively using thematic analysis and grounded theory, to allow a combined inductive/deductive approach to analysis of textual data. Quantitative data will be analyzed using descriptive and inferential statistics in R.

The research activities described in this thesis are funded through a granted FWO-SBO research project. The literature review and FGDs with family physicians have been wrapped-up, with manuscripts published or in review [4-5]. Since other research activities are either in data collection or analysis phase, we aim to finish this thesis by Q4 2023.
Effective start/end date6/07/22 → …