出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : An important dimension of people-centred health systems is the organisation of services around patients’ heterogeneous medical and psychosocial needs rather than around biomedical disease categorisations. This approach may potentially contribute to better treatment outcomes in the field of HIV, since many factors not directly related to HIV, such as the availability of opioid substitution therapy, may determine the extent to which patients benefit from HIV clinical care. Methods : The EuroSIDA study is a prospective observational cohort study that began enrolling patients in 1994. In early 2014, we conducted a 59-item survey of the 98 EuroSIDA clinics. The survey included 10 items relating to various aspects of people-centred health care. Responses from the EuroSIDA East Europe study region (Belarus, Estonia, Lithuania, the Russian Federation and Ukraine [n=12 centres from 5 countries]) were compared to responses from a “non-East Europe” study region comprised of all other EuroSIDA countries (n=70 centres from 26 countries). Differences in responses were assessed using Fisher’s exact test and statistical significance was defined as p<0.05. Results : Drug/alcohol treatment services and opioid substitution therapy (OST) were not available at many EuroSIDA study clinics, with the East Europe group reporting non-significantly lower levels of these services than the non-East Europe group (33% versus 50% and 25% versus 44% respectively) (Figure 1). The East Europe group lagged further behind the non-East Europe group in regard to levels of mental health treatment and/or referral (42% versus 74%, p=0.039), as well as levels of family planning counselling (33% versus 69%, p=0.026). On-site childcare was available at less than two-thirds of clinics in both East Europe and non-East Europe (50% versus 35%). High proportions of clinics in both regions were found to have on-site pharmacies (92% East Europe versus 93% non-East Europe). Significantly lower levels of East Europe clinics reported having foreign-language interpreters available compared to non-East Europe clinics (25% versus 59%, p=0.038). High levels of both East Europe clinics and non-East Europe clinics reported providing the following services to HIV-positive patients for free: clinic visits (83% versus 77%), antiretroviral therapy (ART) (100% versus 83%), CD4 cell count testing (100% versus 78%) and viral load testing (100% versus 83%) (Figure 2).Drugs for opportunistic infections were provided for free at somewhat smaller proportions of clinics (58% East Europe versus 62% non-East Europe). Discussion : Although neither alcohol and drug treatment services nor OST were available at many EuroSIDA clinics within or outside of the East Europe countries, it is not known whether or not this is problematic, since it is common in some settings to have separate narcological facilities located in close proximity to clinics that provide ART. A question warranting further research, particularly in East Europe EuroSIDA clinics, is whether patients with alcohol and drug addiction have sufficient access to treatment and to OST, either on the premises or elsewhere. The HIV literature has identified health service fees as a major barrier to treatment and care, with one potential consequence being loss to follow-up. In our study, the proportions of clinics providing four types of free services were high for both of the regions being compared. At the same time, East Europe clinics responding to the survey reported having higher loss to follow-up than the comparison region (data not shown). Further research should examine these variables on a clinic-by-clinic basis and in relation to patient socioeconomic status to determine how fees might affect patient outcomes in this regard. The regional difference in the provision of foreign-language interpreters may be due to a lower need in the East Europe group of clinics since most people in those study countries, regardless of nationality, speak Russian. On the other hand, a lack of foreign language interpreters in more than 40% of non-East clinics may be indicative of a service access barrier with greater consequences in some of those countries. Again, a closer examination of key variables on a clinic-by-clinic basis is warranted. Conclusion : This investigation of patient-centred health services at EuroSIDA study clinics has identified some service gaps in the East Europe group of clinics and other service gaps in the full cohort of EuroSIDA study clinics across Europe. Further research is needed to determine the potential impact of these gaps on patient outcomes. Figure 1. Availability of people-centred health services (see figure by following link below) P-values from Fishers exact test for comparing proportions. 1N=81 responses: 11 from East and 70 from non-East. 2N=81 responses: 12 from East and 69 from non-East. 3N=80 responses: 12 from East and 68 from non-East. Figure 2. Availability of free services (see figure by following the link below) P-values from Fishers exact test for comparing proportions. ART = antiretroviral therapy; CD4 = CD4 cell count; VL = viral load; OIs = opportunistic infections. All questions had 81 responses: 12 from East and 69 from non-East.
关键词：hiv ; people-centred health systems ; service delivery ; europe
