Optimising the service delivery of HIV pre-exposure prophylaxis (PrEP) : exploring opportunities and challenges in the Belgian health system

Introduction

Oral pre-exposure prophylaxis (PrEP) is a highly effective biomedical HIV prevention tool with a high potential to significantly reduce HIV incidence. In 2017, Belgium was among the first countries in the world to roll-out a national PrEP programme through 12 specialised and multidisciplinary HIV clinics. Lessons learned from HIV care show that centralised delivery can pose considerable logistical and accessibility barriers that may undermine the impact of PrEP. Alternatively, engaging family physicians could offer an attractive strategy to reduce pressure on HIV clinics and bring PrEP closer to the people, but there remain questions around the feasibility and acceptability of this approach.

In this thesis, we aimed to contribute to insights into what could constitute an optimal service delivery model for PrEP in the Belgian context. Specific objectives were: (1) to review service delivery models for PrEP applied in real-world settings globally; (2) to understand how providers have integrated PrEP care in Belgian HIV clinics; (3) to explore experiences with, and preferences for, PrEP service delivery among current PrEP users in Belgium; (4) to gain insights into how family physicians in Belgium perceive their role in the service delivery of PrEP.

Research approach and findings

First, a mapping of the international peer-reviewed and grey literature on PrEP service delivery models was undertaken using a scoping review methodology. In this review, different PrEP service delivery models could be distinguished based on their targeted populations, settings, providers and delivery channels. While PrEP was often provided by medical professionals in specialised settings, we also uncovered an increasing trend towards more de-centralised (e.g. community-based or home-based) models, and including the involvement of non-physician providers (e.g. nurses and pharmacists). M-health and telemedicine was increasingly used to deliver different PrEP care aspects, mainly in high-resource settings.

Then, we conducted a qualitative multiple case study of PrEP implementation in eight Belgian HIV clinics. In each clinic, we conducted interviews with clinic managers and different types of PrEP providers, as well as observations of healthcare settings. We found that PrEP care implementation required considerable adaptive capacity of providers to balance managing the increased workload of a growing PrEP user cohort with adequately responding to clients’ individual care needs. This led providers to re-organising clinic structures, flexibly extending PrEP care norms and re-shaping interprofessional relations (e.g. task-shifting to nurses and involving psychosocial expertise and family physicians). While these findings illustrated PrEP providers’ agency and commitment to creating an enabling environment for multidisciplinary PrEP care, they also revealed a mismatch between practice and policy as some implemented adaptations did not align with policy-issued PrEP reimbursement regulations.

To gain insight into the perspective of PrEP users, we conducted a mixed-methods study that combined data from a web-based longitudinal survey among PrEP users living in Belgium with in-depth interviews with a purposive sample of survey participants. We found that current PrEP users were generally satisfied with the care received in specialised HIV clinics, owing to trust in the vast expertise of HIV clinicians and the ability to access sexual health care in a stigma-free environment. Yet, our findings also revealed service delivery barriers: limited provider-client interactions, difficulties incorporating follow-up visits in users’ private and professional life, and the financial burden of out-of-pocket expenses related to PrEP care. PrEP users valued having access to a comprehensive care package including counselling in mental health and ‘chemsex’. About half of all participants were willing to include their family physician in PrEP care.

Finally, we conducted online group discussions with Belgian family physicians (FPs) to explore their self-perceived roles in PrEP service delivery. Despite their limited PrEP-related knowledge and experience, FPs were willing to be more involved in PrEP care and perceived PrEP as compatible with various roles they already took up as primary care providers. We also found that FPs displayed varying degrees of preferred engagement within these roles, dependent on individual and context-related factors. Minimal roles that every FP should be able to take-on included: providing accurate and unbiased advice on PrEP, referring clients with a PrEP need to specialised services, and participating in follow-up alongside HIV specialists. Many FPs, however, anticipated challenges to manage PrEP care independently due to discomfort and/or time constraints to conduct comprehensive HIV risk assessments, unfamiliarity with sexual health counselling, and a perceived lack of PrEP demand in their client population.

Conclusion

Taken together, our findings suggest that a combined service delivery approach involving both specialised (HIV) services and primary care will likely be needed to ensure broad and sustainable access to PrEP as part of a comprehensive sexual health service in Belgium. To achieve this, there is a need to install policies that legitimise practice-based evolutions towards more simplified and differentiated care models. This will require adequate support and training to increase FPs’ knowledge and competences in providing care sensitive to the sexual health needs of very diverse populations, notably MSM. Future research must be directed at the design, implementation and evaluation of concrete service delivery strategies that fit this approach, also for the provision of novel PrEP formulations.