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Title: From transmission to transition : a multi-method analysis of the HIV treatment and care continuum in the Thai paediatric antiretroviral programme
Author: Tulloch, Olivia Hilary
ISNI:       0000 0004 2737 1303
Awarding Body: University of Liverpool
Current Institution: University of Liverpool
Date of Award: 2011
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In Thailand more than 9,000 HIV-infected children receive free antiretroviral therapy (ART) through the public health system. This pioneering public health programme has received international acclaim but to date there has been no comprehensive evaluation of the various elements that have contributed to its scale-up in the paediatric population. Using a definition of the continuum of paediatric HIV treatment and care that starts at transmission of HIV and ends with transition of adolescents to adult services this thesis analyses it on three levels: policy, provider and service-user. It examines HIV policies and the Children's ART Network (CAN) model; the delivery of paediatric services; and service-users' ability to access treatment services consistently. It aims to document these perspectives to learn lessons of relevance to policy makers and service-providers in Thailand and beyond. The objectives were met using a multi-method approach comprising predominantly qualitative research techniques, supported by quantitative data and triangulation. In order to represent the range of experiences data were collected from sites in two provinces representing each type of service-provider: university, provincial and district hospitals, and two HIV orphanages. The fieldwork took place over 14 months (March 2008-May 2009) and comprised a review of ART policy; interviews with policy "actors" (n=27); focus-group discussions with HIV service-providers (n=3); interviews with HIV-positive adolescents and caregivers (prior and current) of HIV-positive children (n=45); quantitative analysis of hospital and orphanage registry data (n=498); and, a questionnaire survey of service-users (n=252). Evaluation of health policy made clear the importance of pro-poor health reforms in the 1990s and early 2000s that have entitled Thais to free health-care, including H IV services for eligible individuals. The government programme for HIV positive children was designed to address their diagnostic, treatment and support needs in a holistic way. These far reaching measures contributed to the Thai HIV treatment programme being recognised as global leaders of the public health approach to HIV treatment. However, some health-systems and policy gaps have emerged. Policy interviews showed that policy development slowed, partly due to altered financial priorities within the health sector, but also to divisions between the health-financing department and the co-ordinating body of the national AIDS programme. Policies relating to paediatric HIV are fragmented, sometimes poorly implemented and some child-specific elements have been neglected. There are other areas of concern too: HIV incidence - including among pregnant women - have shown indications that it will increase, infant prevention strategies (through PMTCT) have reduced transmission rates but HIV- infected mothers seem less likely to receive antenatal care; children continue to present late for HIV services; and skilled support for adolescents and their transition to adult services is limited. Focus-group discussions revealed highly motivated peer-support volunteers operating in hospitals and the community who provide support to health workers and HIV-affected families throughout the continuum. They would benefit from a more secure funding mechanism and accreditation. Well-trained, dedicated healthcare providers struggle to deliver the standard of service they feel HIV-infected children need. The government programme is scaling-up the 'CAN' model through which children are referred back to receive treatment at district hospitals (supervised by tertiary hospitals), are supported by peer volunteers, and where possible a 'one-stop service' is implemented. It was considered by many respondents as the best way to cover children's diverse care needs across the continuum. Qualitative investigation of patients' and caregivers' experiences showed that many service- users, who are increasingly approaching adolescence, live in extreme poverty with an elevated perception of HIV stigma. To avoid recognition, some travel to distant hospitals for treatment, yet most rural residents are generally very satisfied with the services in their community-focused local district hospital. Most caregivers take treatment adherence and regular clinic attendance very seriously; they value psycho-social support and information they receive from peer-support volunteers highly. The prior caregivers of children living in orphanages suggested that, apart from poverty, the difficulties facing families have changed since ART became widely available. In the pre-ART era stigma and chronic ill health were major reasons for extended families choosing to send children to orphanages. Drug resistance, difficulties with treatment adherence and coping with adolescent behaviour are now more likely to be among the reasons. Quantitative data sources confirmed these findings and found that most children sought treatment late in the course of their HIV disease. This finding is consistent over time despite the introduction of free treatment and of strategies to prevent mother-to-child-transmission (PMTCT) nationwide. Many children at the study sites are orphaned, and live with elderly and poorly educated caregivers with limited treatment literacy and low aspirations. Overall the triangulated findings reveal a high standard of paediatric HIV care is delivered in Thailand through a sophisticated system. Using the concept of a continuum to analyse child HIV services has identified strengths such as strong links between communities and clinics forged by peer supporters. It has also identified some gaps and changes over time. Given the current profile of children entering and already enrolled in the programme now is the time to address missed opportunities for early paediatric treatment, prioritize adolescents' needs and strengthen existing capacity of health-workers and volunteers to identify and respond to children's social, economic and psychological conditions. The national committee that co-ordinates the multi-sectoral HIV policy response could maximize the opportunities presented by the strengths of the current Children's ART Network to better address the entirety and complexity of paediatric needs, rather than paediatrics as an adjunct to adult services.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available