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Abstract：
BACKGROUND: In Belgium, oral HIV pre-exposure prophylaxis (PrEP) is primarily provided in specialized clinical settings. Optimal implementation of PrEP services can help to substantially reduce HIV transmission. However, insights into implementation processes, and their complex interactions with local context, are limited. This study examined factors that influence providers\' adaptive responses in the implementation of PrEP services in Belgian HIV clinics.
METHODS: We conducted a qualitative multiple case study on PrEP care implementation in eight HIV clinics. Thirty-six semi-structured interviews were conducted between January 2021 and May 2022 with a purposive sample of PrEP care providers (e.g. physicians, nurses, psychologists), supplemented by 50 hours of observations of healthcare settings and clinical interactions. Field notes from observations and verbatim interview transcripts were thematically analysed guided by a refined iteration of extended Normalisation Process Theory.
RESULTS: Implementing PrEP care in a centralized service delivery system required considerable adaptive capacity of providers to balance the increasing workload with an adequate response to PrEP users\' individual care needs. As a result, clinic structures were re-organized to allow for more efficient PrEP care processes, compatible with other clinic-level priorities. Providers adapted clinical and policy norms on PrEP care (e.g. related to PrEP prescribing practices and which providers can deliver PrEP services), to flexibly tailor care to individual clients\' situations. Interprofessional relationships were reconfigured in line with organizational and clinical adaptations; these included task-shifting from physicians to nurses, leading them to become increasingly trained and specialized in PrEP care. As nurse involvement grew, they adopted a crucial role in responding to PrEP users\' non-medical needs (e.g. providing psychosocial support). Moreover, clinicians\' growing collaboration with sexologists and psychologists, and interactions with PrEP users\' family physician, became crucial in addressing complex psychosocial needs of PrEP clients, while also alleviating the burden of care on busy HIV clinics.
CONCLUSIONS: Our study in Belgian HIV clinics reveals that the implementation of PrEP care presents a complex-multifaceted-undertaking that requires substantial adaptive work to ensure seamless integration within existing health services. To optimize integration in different settings, policies and guidelines governing PrEP care implementation should allow for sufficient flexibility and tailoring according to respective local health systems.
METHODS: We conducted a qualitative multiple case study on PrEP care implementation in eight HIV clinics. Thirty-six semi-structured interviews were conducted between January 2021 and May 2022 with a purposive sample of PrEP care providers (e.g. physicians, nurses, psychologists), supplemented by 50 hours of observations of healthcare settings and clinical interactions. Field notes from observations and verbatim interview transcripts were thematically analysed guided by a refined iteration of extended Normalisation Process Theory.
RESULTS: Implementing PrEP care in a centralized service delivery system required considerable adaptive capacity of providers to balance the increasing workload with an adequate response to PrEP users\' individual care needs. As a result, clinic structures were re-organized to allow for more efficient PrEP care processes, compatible with other clinic-level priorities. Providers adapted clinical and policy norms on PrEP care (e.g. related to PrEP prescribing practices and which providers can deliver PrEP services), to flexibly tailor care to individual clients\' situations. Interprofessional relationships were reconfigured in line with organizational and clinical adaptations; these included task-shifting from physicians to nurses, leading them to become increasingly trained and specialized in PrEP care. As nurse involvement grew, they adopted a crucial role in responding to PrEP users\' non-medical needs (e.g. providing psychosocial support). Moreover, clinicians\' growing collaboration with sexologists and psychologists, and interactions with PrEP users\' family physician, became crucial in addressing complex psychosocial needs of PrEP clients, while also alleviating the burden of care on busy HIV clinics.
CONCLUSIONS: Our study in Belgian HIV clinics reveals that the implementation of PrEP care presents a complex-multifaceted-undertaking that requires substantial adaptive work to ensure seamless integration within existing health services. To optimize integration in different settings, policies and guidelines governing PrEP care implementation should allow for sufficient flexibility and tailoring according to respective local health systems.
摘要：
背景：在比利时，口服HIV暴露前预防（PrEP）主要在专门的临床环境中提供。PrEP服务的最佳实施可以帮助大大减少艾滋病毒的传播。然而,对实施过程的见解，以及它们与当地环境的复杂互动，是有限的。这项研究调查了影响提供者在比利时HIV诊所实施PrEP服务时的适应性反应的因素。
方法：我们对8个HIV诊所的PrEP护理实施情况进行了定性的多案例研究。在2021年1月至2022年5月之间进行了36次半结构化访谈，其中包括PrEP护理提供者的目的性样本（例如，医生，护士,心理学家)，通过对医疗机构和临床相互作用的50小时观察来补充。在扩展归一化过程理论的精细迭代的指导下，对来自观察和逐字访谈笔录的现场笔记进行了主题分析。
结果：在集中式服务交付系统中实施PrEP护理需要提供者具有相当大的适应能力，以平衡不断增加的工作量和对PrEP用户个人护理需求的充分响应。因此,对临床结构进行了重新组织，以实现更有效的PrEP护理流程，与其他临床级别的优先事项兼容。提供商调整了PrEP护理的临床和政策规范（例如，与PrEP处方实践相关，以及哪些提供商可以提供PrEP服务），灵活地根据个人客户的情况定制护理。根据组织和临床适应重新配置了跨专业关系；这些包括从医生到护士的任务转移，使他们在PrEP护理方面得到越来越多的培训和专业化。随着护士参与的增加，他们在应对PrEP用户的非医疗需求（例如提供社会心理支持）方面发挥了关键作用。此外，临床医生与性学家和心理学家加强合作，以及与PrEP用户家庭医生的互动，在解决PrEP客户的复杂心理社会需求方面变得至关重要，同时也减轻了繁忙的艾滋病毒诊所的护理负担。
结论：我们在比利时HIV诊所的研究表明，PrEP护理的实施是一项复杂的多方面的工作，需要大量的适应性工作来确保与现有卫生服务的无缝整合。要在不同的设置中优化集成，管理PrEP护理实施的政策和指南应允许根据各自的当地卫生系统进行足够的灵活性和定制。
方法：我们对8个HIV诊所的PrEP护理实施情况进行了定性的多案例研究。在2021年1月至2022年5月之间进行了36次半结构化访谈，其中包括PrEP护理提供者的目的性样本（例如，医生，护士,心理学家)，通过对医疗机构和临床相互作用的50小时观察来补充。在扩展归一化过程理论的精细迭代的指导下，对来自观察和逐字访谈笔录的现场笔记进行了主题分析。
结果：在集中式服务交付系统中实施PrEP护理需要提供者具有相当大的适应能力，以平衡不断增加的工作量和对PrEP用户个人护理需求的充分响应。因此,对临床结构进行了重新组织，以实现更有效的PrEP护理流程，与其他临床级别的优先事项兼容。提供商调整了PrEP护理的临床和政策规范（例如，与PrEP处方实践相关，以及哪些提供商可以提供PrEP服务），灵活地根据个人客户的情况定制护理。根据组织和临床适应重新配置了跨专业关系；这些包括从医生到护士的任务转移，使他们在PrEP护理方面得到越来越多的培训和专业化。随着护士参与的增加，他们在应对PrEP用户的非医疗需求（例如提供社会心理支持）方面发挥了关键作用。此外，临床医生与性学家和心理学家加强合作，以及与PrEP用户家庭医生的互动，在解决PrEP客户的复杂心理社会需求方面变得至关重要，同时也减轻了繁忙的艾滋病毒诊所的护理负担。
结论：我们在比利时HIV诊所的研究表明，PrEP护理的实施是一项复杂的多方面的工作，需要大量的适应性工作来确保与现有卫生服务的无缝整合。要在不同的设置中优化集成，管理PrEP护理实施的政策和指南应允许根据各自的当地卫生系统进行足够的灵活性和定制。
