A comparison of attitudes and knowledge of pre-exposure prophylaxis (PrEP) between hospital and Key Population Led Health Service providers: Lessons for Thailand's Universal Health Coverage implementation.

BACKGROUND: HIV Pre-exposure prophylaxis (PrEP) has demonstrated efficacy and effectiveness among high-risk populations. In Thailand, PrEP has been included in the National Guidelines on HIV/AIDS Treatment and Prevention since 2014. As a part of the national monitoring and evaluation framework for Thailand's universal coverage inclusion, this cross-sectional survey was conducted to assess knowledge of, attitudes to and practice (KAP) of PrEP service providers in Thailand.
METHODS: We conducted a cross-sectional survey to explore knowledge of, and attitudes towards PrEP among providers from hospital and Key Population Led Health Services (KPLHS) settings. The questionnaire was distributed online in July 2020. Descriptive and univariate analysis using an independent-sample t-test were applied in the analyses. Attitudes were ranked from the most negative (score of 1) to the most positive (score of 5).
RESULTS: Overall, there were 196 respondents (158 from hospitals and 38 from KPLHS) in which most hospital providers are female nurse practitioners while half of those from KPLHS report current gender as gay. Most respondents report a high level of PrEP knowledge and support provision in all high-risk groups with residual concern regarding anti-retroviral drugs resistance. Over two-fifths of providers from both settings perceive that PrEP would result in risk compensation and half of KPLHS providers are concerned regarding risk of sexual transmitted infections. Limited PrEP counselling time is a challenge for hospital providers.
CONCLUSIONS: Service integration between both settings, more involvement and distribution of KPLHS in reaching key populations would be essential in optimizing PrEP uptake and retention. Continuing support particularly in raising awareness about PrEP among healthcare providers and key populations, facilities and manpower, unlimited quota of patient recruitment and PrEP training to strengthen providers' confidence and knowledge would be essential for successful PrEP implementation.

Introduction

Thailand is among the countries with the highest HIV prevalence in Asia and the Pacific region with an estimated 480,000 people living with HIV in 2018 accounting for 9% of the region’s total HIV infected population [1]. Even though the prevalence has been declining over the past decades due to successful early treatment and prevention programs, HIV remains a significant public health issue of the country. To achieve the country’s ambitious goal in stopping the AIDS epidemic by 2030, a number of strategies including scale-up screening for early HIV treatment and HIV prevention are required to pave the way for disease eradication.

HIV Pre-exposure prophylaxis (PrEP) is the use of antiretroviral medications among uninfected individuals at high risk for HIV infection. The combination of two antiretroviral drugs, 200 mg emtricitabine (FTC) and 300 mg tenofovir disoproxil fumarate (TDF), has been recommended by the World Health Organization (WHO) for use as PrEP in HIV/AIDS before potential HIV risk exposure [2]. The use of medications consistently and correctly has been clinically proven to be effective, and cost-effective among populations with substantial risk of HIV infection [3-6]. In Thailand, PrEP has been included in the National Guidelines on HIV/AIDS Treatment and Prevention by the Ministry of Public Health (MoPH) as an additional measure among high-risk populations since 2014 [7] and become available free of charge under the Universal Health Coverage (UHC) since 2019 [8].

PrEP service in Thailand has been run as a pilot program supported by different sources of funding from both public and private sectors including the Joint United Nations Programme on HIV/AIDS, the Thai Red Cross Princess Soamsawali HIV Prevention (known as ‘Princess PrEP Program’) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. More than 23,000 individuals have been served with PrEP to date [9]. The service can be provided either at hospitals or managed by a network of various community-based organizations where PrEP clients can go to community-based Key Population Led Health Services (KPLHS) for medications and follow-up. The KPLHS model was established in 2015 in response to the needs of the key populations [10,11] at risk for HIV. A defined set of HIV-related health services is provided at KPLHS clinics which are in close proximity to key population communities [12]. The main source of fundings for KPLHS is largely from non-government organizations. The first KPLHS program for marginal population was supported by the Princess Soamsawali HIV Prevention fund under the Thai Red Cross AIDS Research Center of which PrEP services were provided in eight clinics in four provinces (Bangkok, Chonburi, Chiang Mai and Songkhla) [13]. In contrast to the hospital-based model where PrEP is delivered at hospitals by healthcare practitioners, at KPLHS, PrEP is provided by lay providers who are often members of the key populations under a “needs-based, demand-driven, and client-centred” approach in close collaboration with the public health sector to ensure friendly and respectful service access [10,14]. The model has demonstrated feasibility and accessibility in reaching high-risk individuals who are men who have sex with men (MSM), transgender women (TGW), and sex workers (SWs), and people who inject drugs (PWID) contributing two-thirds of new HIV cases in Thailand [15]. The cumulative number of PrEP users in Thailand has been increasing substantially from 1,865 in 2017 to 13,769 in 2021, of which KPLHS accounted approximately two-third of PrEP services [16].

To ensure sustainable service delivery, the National Health Security Office (NHSO) launched a pilot project in 2020 to provide PrEP for 2,000 new clients at 50 PrEP service centers (46 hospitals and 4 KPLHS) in 21 provinces across the country. In this regard, the national monitoring and evaluation (M&E) framework has been adopted to evaluate early implementation. As a part of the M&E process, this cross-sectional survey was conducted to explore knowledge of, attitudes to and practice of PrEP service providers from both hospital and KPLHS settings. The insights gathered would be useful for planning the national PrEP program roll-out under the country’s UHC to maximize its uptake and retention with the ultimate goal of ending AIDS by 2030.

Methods

Design

An anonymous cross-sectional online survey was conducted to examine PrEP service providers’ knowledge of and attitudes towards PrEP service. The survey is comprised of three parts. The first part captures demographic information including age, sex by birth (male, female) and current gender/sexual orientation (gay, bisexual, TGW, other), profession, years of experiences in PrEP services, and their self-knowledge rating about PrEP service from 0 (very poor knowledge) to 9 (very good knowledge). The second part entails attitudes towards PrEP service in terms of the evidence base, experiences, prioritization, effectiveness among risk groups, required support from NHSO/MoPH, and provision. Multi-item scales ranging from 1 to 5 were applied for all attitude questions ranking from the most negative (score of 1) to the most positive attitudes (score of 5). The third part inquires about the first three supports required from NHSO/MoPH regarding PrEP service in comments based on their opinion. The study partially applied similar domains to those used in a survey among Italian healthcare practitioners (HCPs) by Puro et al. [17] and in a survey of UK HCPs by Desai et al. [18]. The final survey used in this study was developed by the M&E research team with inputs from the national PrEP working committee under the Department of Disease Control, Ministry of Public Health. The study was approved by the Research Ethics Committee, Faculty of Public Health, Chiang Mai University, Thailand (Document No. ET017/2020). Respondents were informed that their participation was voluntary and willingness to participate was confirmed and checked at the beginning of the online questionnaire in order to proceed with the completion.

Participant recruitment

A Quick Response (QR) code, a type of barcode containing information as “a series of pixels in a square-shaped grid” which can be read easily by a digital device [19] was used to store the anonymous self-administered online survey and distributed to all 50 active PrEP centers (46 hospitals and 4 KPLHS) across the country in 21 provinces. In addition, the online survey link and QR code were also provided via a social media chat group under LINE, the most-downloaded social media application for instant messaging [20] among PrEP service providers under NHSO and the national PrEP working committee created as an internal communication channel for monitoring and consultation. The participants were staff engaging in PrEP service delivery and counselling to PrEP clients. The survey responses were collected in July 2020.

Data analysis

STATA version 16.1 (College Station, Texas, USA) was used for statistical analysis. Descriptive analysis was applied for demographic data overall and by type of service delivery model (KPLHS and hospital). Attitudes were ranked from the most negative to the most positive among all respondents in which the responses were categorized into negative attitude (strongly disagree and disagree), undecided, and positive attitude (agree and strongly agree) using positive statements for ease of comparison (the original statements were provided in S1 Table). Univariate analysis using an independent-sample t-test was employed to determine the difference of the mean scores of self-rated PrEP knowledge between KPLHS and hospital groups. Free text responses were quantified and coded into similar categories. Missing values were excluded from analyses.

Results

Respondent characteristics

The survey was completed by 196 PrEP service providers from all 50 PrEP service centers (46 hospitals and 4 KPLHS) under NHSO in Thailand. The four KPLHS were Rainbow Sky Association of Thailand (RSAT), Service Workers in Group (SWING), MPlus, and Caremat. MPlus delivers PrEP service on behalf of Nakornping hospital while PrEP service at SWING, RSAT and Caremat was operated on behalf of the Thai Red Cross AIDS Research Center (Anonymous Clinic). Among these, 38 people were from 4 KPLHS while 158 respondents were from 46 hospitals. The majority of participants sex by birth from hospitals were female (n = 132, 84.54%) whereas most service providers from KPLHS were male (n = 34, 89.47%). Half of these male service providers by current gender were gay, and nearly one fourth (n = 9, 23.68%) were TGW, while one each identified themselves as ‘bisexual’, and other. The mean age of respondents from hospitals and KPLHS were approximately 44 years and 34 years, respectively (Table 1).

Table 1

Respondent demographics.

	Overall (%)(N = 196)Mean±SD*	Hospital (%) (n = 158)Mean±SD*	KPLHS (%)(n = 38)Mean±SD*	P-value
Sex (by birth)    Male    Female	60 (30.61)136 (69.39)	26 (16.46)132 (84.54)	34 (89.47)4 (10.53)	< 0.001
Current gender    Male    Female    Gay    Bisexual    TGW    Other e.g., lesbian, transgender man etc.	19 (9.69)132 (67.35)27 (13.78)3 (1.53)12 (6.12)3 (1.53)	13 (8.23)128 (81.01)10 (6.33)2 (1.27)3 (1.90)2 (1.27)	6 (15.97)4 (10.53)17 (44.74)1 (2.63)9 (23.68)1 (2.63)	< 0.001
Age (year) (mean±SD)	41.80±10.70	43.58±10.19	34.37± 9.62	< 0.001
Profession    Nurse    Physician    Pharmacist    Medical technician    Traditional physician    Public health officer        No healthcare professional license†	92 (46.94)9 (4.59)22 (11.22)3 (1.53)2 (1.02)3 (1.53)65 (33.16)	91 (57.59)9 (5.70)21 (13.29)3 (1.90)1 (0.63)3 (1.90)30 (18.99)	1 (2.63)01 (2.63)01 (2.63)035 (92.11)	< 0.001

Note

*SD: Standard deviation

†: At KPLHS, PrEP counselling is generally provided by trained lay providers who are not HCPs. Blood collection/sampling is done separately by technicians who are not engaged in PrEP counselling.

Nurse was reported as the healthcare practitioner most involved in PrEP service at hospitals (91 of 158; 57.59%), followed by pharmacist (21 of 158; 13.29%) and physicians (9 of 158; 5.7%). The majority of service providers at KPLHS were reported as trained and qualified lay PrEP counsellors who did not hold any HCP license (35 of 38; 92.11%) while one each was a nurse, pharmacist, and traditional physician, a licensed practitioner of Thai traditional medicine from the Thai Traditional Medical Council [21].

Most service providers reported receiving one or more PrEP trainings (79.75% hospital vs. 97.37% KPLHS). Similarly, the majority of respondents reported they were experienced in delivering PrEP service especially those from KPLHS settings in which half of them reported over two years experience in PrEP. The overall self-rating score of PrEP knowledge was 6.74 (Table 2). The majority of respondents rated their PrEP knowledge score over 6 out of 9. Among these, nearly all KPLHS (94.74%), and around three-fourths of hospital providers (75.95%) rated their knowledge as either good or very good (Fig 1).

Table 2

Experiences in PrEP services and knowledge of PrEP.

	Overall (%)(N = 196)Mean±SD*	Hospital (%) (n = 158)Mean±SD*	KPLHS (%)(n = 38)Mean±SD*	P-value
PrEP training received since 2017  No  Yes    •1 time    •2 times    •3 times    •> 4 times	33 (16.84)163 (83.16)53 (27.04)44 (22.45)21 (10.71)45 (22.96)	32 (20.25)126 (79.75)44 (27.85)33 (20.89)15 (9.49)34 (21.25)	1 (2.63)37 (97.37)9 (23.68)11 (28.95)6 (15.79)11 (28.95)	0.009
PrEP service experiences (year)    •< 1 year    •1–2 years    •2–4 years    •> 4 years  Missing	63 (32.14)61 (31.12)59 (30.10)12 (6.12)1 (0.51)	56 (35.44)49 (31.01)44 (27.85)8 (5.06)1 (0.63)	7 (18.42)12 (31.58)15 (39.47)4 (10.53)0	0.209
How would you rate your knowledge of PrEP? (from 0 to 9)	6.74± 2.07	6.59±2.07	7.37±2.00	0.038

Note

*SD: Standard deviation.

Fig 1

Self-rated knowledge of PrEP by service delivery model (hospital vs. KPLHS).

Attitudes towards PrEP

Table 3 and Fig 2 present overall service providers’ attitudes to PrEP in terms of the evidence base, service delivery experiences, prioritization, effectiveness among risk groups, required support from NHSO/MoPH, and provision. The overall attitudes to PrEP service were quite positive from both settings.

Table 3

Hospital and Key Population-Led Health Services providers’ attitudes towards PrEP.

		Hospital			Key Population-Led Health Services
1.	Attitude statements in the evidence base	Negative attituden (%)	Undecidedn (%)	Positive attiuden (%)	Negative attituden (%)	Undecidedn (%)	Positive attiuden (%)
1.1	PrEP is an effective prevention tool in the “real world”	34(21.52)	18(11.39)	106(67.09)	5(13.16)	2(5.26)	31(81.58)
1.2	Taking PrEP consistently can prevent HIV infection > 90%	4(2.53)	4(2.53)	150(94.94)	0	0	38(100.00)
1.3	Little impact of PrEP on ARV resistance	92(58.23)	16(10.53)	50(31.65)	26(68.42)	4(10.53)	8(21.05)
1.4	Taking PrEP for a long time will not lead to more adverse events	53(33.54)	31(19.62)	74(46.84)	10(26.32)	3(7.89)	25(65.79)
2.	Attitude statements in service delivery experiences	Negative attituden (%)	Undecidedn (%)	Positive attiuden (%)	Negative attituden (%)	Undecidedn (%)	Positive attiuden (%)
2.1	Patients will adhere to daily PrEP	36(22.78)	33(20.89)	89(56.33)	12(31.58)	9(23.68)	17(44.74)
2.2	PrEP will not result to risk compensation (less condom use)	69(43.67)	36(22.78)	53(33.54)	17(44.74)	7(18.42)	14(36.84)
2.3	PrEP will not lead to increased STIs	27(17.09)	41(25.95)	90(56.96)	20(52.63)	4(10.53)	14(36.84)
2.4	Long-term PrEP use would not cause frequent adverse events	16(10.13)	45(28.48)	97(61.39)	6(15.79)	5(13.16)	27(71.05)
2.5	Patients won’t be perceived as HIV positive by their partners	52(32.91)	28(17.72)	78(49.37)	14(36.84)	6(15.79)	18(47.37)
2.6	PrEP won’t cause patients an increased likelihood of more sexual partners	39(24.68)	65(41.14)	54(34.81)	14(36.84)	6(15.79)	18(47.37)
2.7	PrEP won’t result in more needle and syringe sharing	9(5.70)	64(40.51)	85(53.80)	3(7.89)	12(31.58)	23(60.53)
2.8	Time to engage in PrEP counselling	66(41.77)	13(8.23)	79(50.00)	11(28.95)	3(7.89)	24(63.16)
3.	Attitude statements in prioritization	Negative attituden (%)	Undecidedn (%)	Positive attiuden (%)	Negative attituden (%)	Undecidedn (%)	Positive attiuden (%)
3.1	PrEP will have a greater impact than behavioral interventions on HIV prevention	89(56.33)	25(15.82)	44(27.85)	15(39.47)	5(13.16)	18(47.37)
3.2	PrEP will have a greater impact than counselling and VCT	56(35.44)	20(12.66)	82(51.90)	13(34.21)	3(7.89)	22(57.89)
3.3	PrEP should be made available for free to ALL patients who request it	35(22.15)	16(10.13)	107(67.72)	9(23.68)	0	29(76.32)
3.4	PrEP should be made available for free to only those with high risk of acquiring HIV infection	46(29.11)	7(4.43)	105(66.46)	17(44.74)	1(2.63)	20(52.63)
3.5	Those with no or low risk in acquiring HIV should pay for PrEP if they request it	73(46.20)	24(15.19)	61(38.61)	24(63.16)	4(10.53)	10(26.32)
3.6	PrEP costs less than care on the HIV epidemic	4(2.53)	9(5.70)	145(91.77)	3(7.89)	2(5.26)	33(86.84)
3.7	PrEP service should be provided together with condom use counselling and STI testing	3(1.90)	1(0.63)	154(97.47)	0	0	38(100.00)
3.8	PrEP should not be stopped immediately if patients do not adhere to daily PrEP	75(47.47)	20(12.66)	63(39.87)	13(34.21)	0	25(65.79)
3.9	PrEP should not be stopped in patients with frequent STIs	59(37.34)	14(8.86)	85(53.80)	10(26.32)	2(5.26)	26(68.42)
4.	Attitude statements in effectiveness	Negative attituden (%)	Undecidedn (%)	Positive attiduen (%)	Negative attituden (%)	Undecidedn (%)	Positive attiduen (%)
4.1	PrEP is effective among MSMs	1(0.63)	6(3.80)	151(95.57)	0	0	38(100.00)
4.2	PrEP is effective among TGW	58(36.71)	13(8.23)	87(55.06)	0	2(5.26)	36(94.74)
4.3	PrEP is effective among serodiscordant couples	2(1.27)	9(5.70)	147(93.04)	0	1(2.63)	37(97.37)
4.4	PrEP is effective among PWIDs	8(5.06)	24(15.19)	126(79.75)	0	1(2.63)	37(97.37)
4.5	PrEP is effective among sex workers	2(1.27)	4(2.73)	152(96.20)	1(2.63)	1(2.63)	36(94.74)
5.	Support needed from NHSO/MoPH	Negative attituden (%)	Undecidedn (%)	Positive attiduen (%)	Negative attituden (%)	Undecidedn (%)	Positive attiduen (%)
5.1	PrEP training at least once a year	1(0.63)	0	157(99.37)	2(5.26)	0	36(94.74)
5.2	Promotion of PrEP to public through medias and online channels	2(1.27)	1(0.63)	155(98.10)	0	0	38(100)
5.3	Free PrEP without quota limitation to risk groups	4(2.53)	3(1.90)	151(95.57)	2(5.26)	0	36(94.74)
5.4	Human resource	0	2(1.27)	156(98.73)	0	1(2.63)	37(97.37)
5.5	System monitoring and center visit at least once a year	3(1.90)	6(3.80)	149(94.30)	2(5.26)	0	36(94.74)
6.	“PrEP service should be available ……”	Negative attituden (%)	Undecidedn (%)	Positive attiduen (%)	Negative attituden (%)	Undecidedn (%)	Positive attiduen (%)
6.1	… at all government hospitals under NHSO	2(1.27)	2(1.27)	154(97.47)	0	2(5.26)	36(94.74)
6.2	. . .at all private hospitals under NHSO	3(1.90)	12(7.59)	143(90.51)	0	3(7.89)	35(92.11)
6.3	. . . at certified subdistrict health promotion hospitals	26(16.46)	21(13.29)	111(70.25)	2(5.26)	6(15.79)	30(78.95)
6.4	. . . at qualified KPLHS	17(10.76)	19(12.03)	122(77.22)	1(2.63)	2(5.26)	35(92.11)
6.5	. . . at certified private pharmacies	33(20.89)	28(17.72)	97(61.39)	16(42.11)	2(5.26)	20(52.63)

Fig 2

Service providers’ attitudes towards PrEP service.

The evidence based

About one-third of respondents from hospitals and most KPLHS providers reported a positive attitude to the statement that PrEP is an effective prevention tool in the real world (67.09% hospital vs. 81.58% KPLHS) while nearly all participants reported a positive attitude to the statement that taking PrEP consistently would provide more than ninety percent protection against HIV infection (94.94% hospital vs. 100% KPLHS). Nearly sixty percent and seventy percent of respondents from hospital and KPLHS settings respectively reported a negative attitude to the statement that PrEP would have little impact on anti-retroviral (ARV) drugs resistance (58.23% hospital vs. 68.42% KPLHS) whereas about half of hospital and two thirds of KPLHS providers reported a positive attitude to taking PrEP for a long term would not lead to more adverse events (46.84% hospital vs. 65.79%). Respondents from KPLHS were slightly more positive in terms of the evidence compared to those from hospitals (Table 3) (Fig 2).

Service delivery experiences

More than half and nearly half of service providers from hospitals and KPLHS respectively reported a positive attitude to patients’ adherence to daily PrEP (56.33% hospital vs. 44.74% KPLHS). Over forty percent of providers from both settings reported a negative attitude to the statement that PrEP would not result in risk compensation. More than half of hospital providers reported a positive attitude that PrEP would not result in more sexually transmitted infections (STIs) whereas a similar proportion of individuals from KPLHS reported the opposite. Approximately half of all respondents reported a positive attitude that taking PrEP would neither cause more needle/syringe sharing nor stigmatization to be perceived as HIV positive by their partners. More than two-fifths of providers from hospitals (41.77%) reported that they did not have enough time to engage in PrEP counselling compared to 29% of providers from KPLHS. Overall, there was no difference in attitudes in terms of service delivery experiences between participants from either type of service delivery model apart from attitudes regarding increase in STIs and time for counselling (Table 3) (Fig 2).

Prioritization

Over half and one-third of respondents from hospitals and KPLHS respectively reported a negative attitude that PrEP had a greater impact than behavioural interventions on HIV prevention (56.33% hospital vs. 39.47% KPLHS) while more than half of individuals from both settings reported that PrEP will have a greater impact than counselling and VCT (Voluntary Counselling and Testing) (51.90% hospital vs. 57.89% KPLHS). Sixty-nine percent (69.4%) of all respondents reported that PrEP should be made available for free to all patients requesting it whereas sixty-four percent (63.8%) reported a positive attitude to availability of free PrEP only to those at high-risk of acquiring HIV. Nearly half and two-third of participants from hospital and KPLHS respectively reported a positive attitude to patients with no or low risk paying for their own PrEP service (46.20% hospital vs. 63.16% KPLHS). PrEP was reported to cost less than care for HIV endemic (90.8%) and to be provided together with condom use counselling and STIs testing (98%) by the majority of participants. About two-thirds of respondents from KPLHS reported that PrEP should not be stopped immediately in case of non-adherence (65.79%) or frequent STIs (68.42%) compared to only about forty percent, and half of individuals from hospital settings (39.87% and 53.80%). The overall attitudes to PrEP in terms of prioritization was slightly more positive among service providers from KPLHS compared to those from hospital settings (Table 3) (Fig 2).

Effectiveness

The majority of respondents reported a positive attitude regarding the effectiveness of PrEP among MSM (96.4%), serodiscordants couples (93.9%), PWIDs (83.2%), and sex workers (95.9%). Almost all participants from KPLHS reported a positive attitude to PrEP effectiveness among TGW as compared to only approximately half of providers from hospitals (94.74% KPLHS vs. 55.1% hospital). Both respondents from KPLHS and hospital providers reported similar positive attitudes to PrEP in terms of effectiveness except effectiveness among TGW (Table 3) (Fig 2).

Support needed for PrEP service

Nearly all participants reported a positive attitude for more support from NHSO/MoPH in delivering PrEP service. These included organizing PrEP training at least once a year (98.5%), promotion of PrEP to public (98.5%), unlimited quota in recruiting PrEP clients (95.4%), additional manpower (98.5%), and comprehensive program monitoring system (94.4%). The supports highlighted were similar among the two types of service delivery models (Table 3).

Provision of PrEP service

Most of respondents reported a positive attitude to the provision of PrEP at all government hospitals (96.9%), and private hospitals under NHSO (90.8%), KPLHS and subdistrict health promotion hospitals that have been certified for PrEP service (80.1%) whereas approximately sixty percent of participants reported a positive attitude to targeted PrEP availability at certified private pharmacies. The support of PrEP availability was similar among respondents from both settings (Table 3).

Supports needed

Responses regarding the first three supports required from NHSO/MoPH were completed by 129 respondents (129 out of 196 respondents, 65.82%). The required supports were broken down into four main categories which were skills and training, facilities and manpower, service system improvement, and promotion of PrEP service. Overall, most service providers reported a positive attitude to support in terms of facilities and manpower (90.70%), followed by promotion of PrEP service (55.81%), service system improvement (41.86%), and skills and training (38.76%) (Table 4).

Table 4

Support needed for PrEP service delivery.

The first 3 supports needed*	Overall (%)(N = 129)	Hospital (%)(n = 101)	KPLHS (%)(n = 28)
Promotion of PrEP service    •Raising public awareness of PrEP and improve public understanding    •Certification for PrEP service providers/centersSkills and trainingFacilities and manpower    •FUNDING**    •Human resource    •Media/materials for clients    •Free condoms and/or lubricants    •Medicine or drug supplies    •Counselling venue    •National PrEP guidelineSystem improvement    •Free/unlimited quota of PrEP service    •Single system for data entry    •Increase the number of PrEP center    •More CBOs/KPLHS involvementOthers†	68 (52.71)4 (3.10)50 (38.76)29 (22.48)24 (18.6)20 (15.50)16 (12.40)14 (10.85)8 (6.20)6 (4.65)28 (21.71)17 (13.18)6 (4.56)3 (2.33)30 (23.26)	51 (50.50)1 (0.99)36 (35.64)24 (23.76)21 (20.79)17 (16.83)15 (14.85)13 (12.87)6 (5.94)5 (4.95)18 (17.82)14 (13.86)3 (2.97)1 (0.99)27 (26.73)	17 (60.71)3 (10.71)14 (50.00)5 (17.86)3 (10.71)3 (10.71)1 (3.57)1 (3.57)2 (7.14)1 (3.57)10 (35.71)3 (10.71)3 (10.71)2 (7.14)3 (10.71)

Note

*responses from 129 respondents (101 from hospitals and 28 from KPLHS)

**includes laboratory cost, traveling expenses for PrEP clients, outreach activities; †include access improvement, separation PrEP from ARV, support from management/executive level, incentive/renumeration, effective coordination from NHSO, PrEP on demand, PrEP packaging improvement, 24 hours hotline service for PrEP inquiries; CBOs, Community-based organizations; KPLHS, Key-Population (KP)-led health services.

Raising awareness about PrEP program and improving public understanding was the most frequent support needed reported with a positive attitude by service providers from hospitals (50.50%), followed by PrEP training (35.64%), others including support from executive level, incentive and renumeration, and separation of PrEP service from ARV (26.73%), funding including laboratory cost, travelling expenses for clients, and outreach activities (23.76%), and manpower (20.79%) whereas raising PrEP awareness was the most positive attitude reported by respondents from KPLHS (60.71%), followed by training (50.00%), unlimited quota for client recruitment (35.71%), and funding (17.86%). The main suggestions from free text responses included advertisement of PrEP service via multiple channels to a wider population to improve understanding and access to individuals who have risk in acquiring HIV, more supplies of lubricants and condoms at required sizes (52”, 54” and 56”), and service system improvement in minimizing overlapping data to be entered into different programs.

Discussion

To the authors’ knowledge, this is the first study to compare knowledge of and attitudes towards PrEP between hospital and KPLHS providers from all active PrEP centers in Thailand. These data provide important insights for the design and benefits of UHC implementation. PrEP providers from both types of service delivery models are different in terms of characteristics, attitudes to some extent, and priority support needed. Most service providers from hospitals are female healthcare practitioners in which the majority are nurses at their middle-age whereas the majority of providers from KPLHS are males in their thirties in which half of them identify themselves as gay, followed by TGW. This emphasizes the contrast between the two-service delivery models and demonstrates the shifting of service delivery through lay providers in KPLHS setting. In the context of HIV endemic in Thailand, which is mainly among key populations including MSM, TGW, SWs, the KPLHS approach comprising providers who are also members of key populations seems to be a feasible and effective model to optimize contextual knowledge and connections in serving hard to reach individuals who are at high-risk [10]. The model demonstrates feasibility, acceptability, and affordability as well as broadens options for service delivery among those who are in need [10,22]. Close collaboration with the public health sector regarding the design and delivery of service is essential to ensure friendliness, non-stigmatizing, respect, confidentiality, and adherence to the national guidelines and standards [10,23]. Although KPLHS have been legalized for PrEP provision in Thailand, KPLHS clinics have not been certified and cannot be reimbursed directly from the NHSO. Therefore, the funding mechanism for differentiated service delivery models to facilitate integration of KPLHS under the UHC is key to ensure sustainability and high coverage among KP.

Overall, PrEP service providers in Thailand have positive attitudes towards PrEP. The majority of participants report a high level of perceived knowledge in PrEP especially those from KPLHS and supports PrEP provision in all high-risk groups. Attitudes towards the evidence base are positive with residual concern on the impact of PrEP on ARV resistance. In terms of service delivery experiences, over two-fifths of respondents are concerned that PrEP would lead to an increase in risk behaviors (risk compensation) while more than half of participants from KPLHS are concerned that PrEP use would result in more STIs. Time to engage in PrEP counselling seems to be an aggravating barrier particularly among hospital providers. Nearly all respondents perceive that PrEP costs less than care for HIV and discern the importance of providing PrEP service together with condoms and STIs testing/counselling. PrEP is perceived to be effective in all risk groups including MSMs, TGW, serodiscordant couples, PWIDs, and sex workers. The effectiveness of PrEP among TGW is perceived by nearly all providers from KPLHS but only about half of hospital providers. This indicates the need for TGW specific health services delivered by key population providers. The concern over potential drug-drug interactions of feminizing hormone and PrEP is an important barrier that impedes PrEP uptake among TGW [24]. Therefore, there is a need for more specific training concerning TGW’s health concerns in addition to regular annual PrEP training by MoPH which usually entails PrEP use, potential side effects, and counselling to equip KPLHS lay providers in enhancing PrEP uptake and retention. The reason that hospital providers showed higher negative attitude concerning effectiveness of PrEP among TGW was probably due to their limited experiences among TGW population. Hence, sensitizing or training on transgender-related health issues focusing on service provision tailored at individual level should also be considered to improve the capacity among hospital providers to advise clients with specific needs.

The residual concern on antiretroviral resistance is in line with previous findings [17,18,25] but to a lesser extent despite a very low risk in developing drug resistance [26,27]. Findings from randomized controlled trials suggest very little impact of PrEP on ARV resistance [26-28] and this should be addressed into any PrEP education and training. Over forty percent of respondents perceive that PrEP would lead to an increase in risk behaviors but only a relatively low proportion were concerned that taking PrEP would result in stigmatization. This is in contrast with previous reports from the U.S. [29] but consistent with a cross-sectional survey among healthcare providers in the UK [18]. Inconsistency of findings could be attributable to differences in experiences and knowledge as most service providers in Thailand have several years of experiences in PrEP while the study in the U.S. was carried out during early PrEP implementation [29].

Most service providers support PrEP availability at hospitals and qualified KPLHS whereas over forty percent of service providers from KPLHS have concern regarding PrEP service delivered at pharmacies. The lowest support of PrEP availability at pharmacies compared to other settings is probably due to limitations in terms of counselling venue, long-term monitoring of PrEP uptake and adverse events. This highlights the importance of culturally sensitive, and personalized service and confidentiality for PrEP clients. This is in contrast to some settings including the U.S. and Australia where “community pharmacy PrEP”has been made widely available and pharmacists play a key role in the national goals enhancing PrEP uptake and ending HIV endemic [30,31]. Endorsement and support of PrEP provision at community pharmacies are challenging and can be an important element to enhance HIV prevention efforts.

KPLHS model has advantages over a hospital model in reaching and recruiting potential PrEP clients through lay providers [10,32,33]. The first PrEP demonstration project at seven KP-friendly clinics in the Democratic Republic of the Congo showed high uptake and acceptability among KP clients [34] whereas a study from a gay-friendly MSM HIV/STI clinic in Sweden revealed that targeting high-risk population with HIV risk individuals such as MSM was highly effective and could significantly reduce the long-term HIV prevalence [35]. KPLHS is also the main component of PrEP service delivery model in Vietnam [8]. The service includes integrated home lab sample collections and HIV testing along with telehealth and courier PrEP delivery during the COVID-19 pandemic [8]. Consistently, the key population-led PrEP program demonstration project was successfully completed in the Philippines and the country is moving forward towards the national implementation [8].

At hospital settings where PrEP service is usually delivered by healthcare professionals and integrated with ARV, STI clinics and VCT, active client recruitment and mobile VCT would be challenging considering the high workload. Moreover, PrEP service at hospitals usually opens during office hours while PrEP service at KPLHS also operates in the evening which is more convenient for working clients [36]. The same-day PrEP initiation which is practiced at KPLHS is also a key success factor of client recruitment to minimize leakage in the cascade [36]. Collaboration between hospitals and KPLHS and having more PrEP centers especially in proximity of key population communities should be encouraged in order to reach more potential PrEP users and to expand service access.

Challenges in delivering PrEP services are raised including lack of awareness about PrEP both among HCPs and potential PrEP clients, high workload, limited manpower, space for counselling, and coverage of the benefit package under UHC. Awareness of PrEP is certainly a crucial step to PrEP access [37-39]. The low level of PrEP awareness is a significant barrier to PrEP initiation [40,41]. According to a recent study among Thai MSM and TGW adolescents, only 18% of participants had heard about PrEP, and 31% intended to initiate PrEP [42]. Social media and online platforms have been widely utilized in key population communities [10]. The online tool has also been applied for their network mappings, outreach activities, and appointment reservation [10]. Taking advantage of social media platforms in promoting PrEP to wider audiences would be important to improve public understanding and increase uptake of the program. The concern about workload is partly attributed to overlapping programs for data entry from different sources of funding which also impedes the country PrEP cascades estimation [36]. The limited coverage of UHC including laboratory cost is problematic for clients who need additional renal function monitoring which would incur out of pocket healthcare expenditure [36].

To our knowledge, this is the first national survey involving PrEP service providers from all active PrEP centers at both hospital and KPLHS settings. Therefore, the results of this survey could represent service providers’ insights for PrEP service in Thailand. However, some limitations can be noted in our study. First, we were unable to calculate the response rate as the online survey was distributed to each PrEP center via QR code and redistributed among participants to their colleagues who were involved with PrEP service and counselling. The majority of respondents had many years of experience in PrEP service and rated high perceived knowledge about PrEP which reflects long-time adoption of PrEP in the country through various sources of funding. Therefore, the results may not represent attitudes of new PrEP providers and might not be applicable to settings who have recently adopted PrEP services. The difference of respondents’ characteristics between hospital and KPLHS settings might influence attitudes towards PrEP. The fact that most KPLHS providers are members of key population communities would probably have affected the results with slightly more positive attitudes about PrEP compared to hospital settings. Finally, most participants rated a high level of perceived knowledge about PrEP (score over 6 out of 9). This self-rated knowledge is subjective and could be influenced by other factors e.g., gender, age etc. However, the result is consistent with experiences and the number of PrEP trainings received by respondents which are indicative of a high level of knowledge.

Conclusions

Although PrEP service providers from both settings (hospital and KPLHS) in Thailand are different in terms of characteristics, most service providers have positive attitudes towards PrEP with residual concerns regarding ARV resistance. Integration of PrEP service from both service delivery types and more involvement and distribution of KPLHS in reaching key populations would be vital in optimizing PrEP uptake and retention. The modest support for PrEP availability at pharmacies may reflect the residual concern of privacy and long-term monitoring. Continuing support particularly in raising awareness about PrEP among HCPs and key populations, facilities and manpower, unlimited quota of patient recruitment and PrEP training to strengthen providers’ confidence and knowledge would be essential for successful PrEP implementation.

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1 Feb 2022

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Reviewer #1: Overall, research method is somewhat questionable and can easily introduce the bias to interpret the study and make the whole study not valid. The number of participants were small and skewed towards people from KPLHS. I would suggest authors to describe the temporal trends of the PrEP uptake in Thailand to see a clearer picture and compare whether KPLHS in other countries do provide PrEP in the same manner as in Thailand.

Page 6, line 131. How many missing values were excluded from the analysis? Did that create a bias?

Page 6, line 136-138 and Page 18 Line 343-346. Please explain why more people per KPLHS responded more than per hospital? Is there any incentive to answer the questionnaire? Why did the research team choose these 4 KPLHS? Do they provide more PrEP services than the hospitals?

Page 7, line 148. Please explain what is traditional physician and provide more detail about the right to prescribe PrEP by traditional physician in Thailand.

Page 11, Line 171. Unclear if the title is completed.

Page 13, Line 225. I would suggest to add these answers to the background or discussion. What kind of training and how often the training occur currently? Any particular certificates needed prior to be PrEP providers?

Reviewer #2: Summary

This study aimed to determine the KAP of PrEP service providers from hospitals and HPLHS to aid in planning for the roll-out of PrEP amid the UHC. The authors did a cross-sectional online survey among PrEP providers in KPLHS and hospitals to assess their knowledge and attitudes. Although qualitative data may have been collected through comments (part 3), data and analysis have been done mostly quantitatively. They used descriptive statistics to summarize the data and independent t-test to compare means. Their results showed significant differences between the characteristics, knowledge and attitude in PrEP provision, and identified needed support between providers of KPLHS and the hospitals. This study not only provided insights on the key role of the KPLHS but also the role of UHC in provision of PrEP.

Largely, I believe that this is a very well-written and strong manuscript. The analysis on UHC, if further strengthened, is very timely and could help other countries shape their HIV service delivery amid transition towards the UHC. I do, however, have several comments for your consideration to further improve the manuscript for publication.

Introduction

In general: Kindly consider providing context on the state of the UHC implementation in Thailand (particularly, whether PrEP is considered a public-level intervention that the cost of which will be covered by the government). Could also consider clarifying describing the role of KPLHS in the primary care setting amid the UHC - i.e., does it receive funding from the government, does it heavily depend on donor funding? Lastly, could consider providing information whether PrEP is accessible for free or at-cost.

Kindly consider changing from "AIDs" to "AIDS"

Page 3, line 58-59 - Could the authors clarify if this is AIDS epidemic, endemic, or pandemic?

Methods

Page 4, line 93: There was no adequate description of the study settings, especially how KPLHS fit into the larger picture of UHC implementation in Thailand.

Page 4, line 98 - Bisexual is not gender but a sexual orientation. Gender indentity can be cis-gender, transgender, or non-binary. Sexual orientation includes homosexual, bisexual, and etc. Moreover, TGW can self-identify as homosexual, bisexual, and etc.

Page 5, line 101 - NHSO should be spelled out.

Page 5, line 105 - when we say "in comments", do the authors mean qualitatively? This could be clarified further. Moreover, it could be clarified whether how the "first three" were collected - were these based on the first three that come into the participants' minds or based on necessity?

Page 5, line 113 - The authors could consider removing the definition of QR code for brevity.

Page 5, line 113-121 - Sampling technique was not discussed. The authors could further explain the technique and calculations, if necessary. Inclusion and exclusion criteria for participants were not explicitly stated.

Page 7, line 148 - Can the authors clarify what a "traditional physician" is?

Results

Page 7, Table 1 - Can the authors clarify the purpose of the variable "current gender"? I am aware that it is challenging to classify participants based on SOGIE but it is recommended that the decision on classification would depend on the research question. As mentioned in the earlier comment, sexual orientation and gender identity are 2 different concepts that TGW can identify themselves as lesbians or gay, as well. Hence, I would recommend revisiting this variable and putting the research question at heart. If it was only intended to illustrate that the KPLHS services were mostly facilitated by KP (cisgender MSM and TGW), then mentioning "KP group", with classifications such as (1) cis-MSM, (2) TGW, and (3) heterosexual male and female, would I think be suffice. See table in https://doi.org/10.1016/S2352-3018(18)30148-6 as an example.

Page 7, line 150-152 - The way the authors explained the context at KPLHS was commendable. I would suggest putting this in the main text rather than a table caption.

Discussion

Page 15-16, lines 263-279 - I commend the authors providing insight in the KPLHS. It is indeed key to addressing the disproportionate increase in HIV incidence among KP in Thailand. However, it could also be interesting if there were insights on the hospitals as PrEP providers and the integration of the KPLHS in the primary care setting amid the UHC. Discussions like these have to be started, especially as many low- and middle-income countries are transitioning towards the UHC and that donor funding in HIV is decreasing.

Page 16, lines 281-296 - Pretty good insight on the attitudes of providers. Do the authors likewise think that their attitudes might be influenced by their clientèle profile? It would be interesting to note whether hypothetically most of the MSM and TGW are being provided PrEP in the KPLHS, whereas sex workers are mostly accessing in the hospital. Is there such data in Thailand that could provide insights on this?

Page 16, lines 292-293 - Negative attitude on effectiveness of PrEP on TGW among hospital providers was higher than in the KPLHS. I really commend the authors for emphasizing this as based on Figure 2, it seems that there was a disproportionately higher negative attitude among hospital providers specifically to this. The authors could also reconsider hospitals being sensitized or trained on transgender-related health issues and not only rely on KPLHS for service delivery. Conversely, this could open discussions for the attitudes of TGW among hospital providers and their preference for KPLHS. Nonetheless, I think there is always benefit in investigating this point further.

Page 17, lines 307-316 - Great insights!

Page 18, lines 338-340 - More context is needed here. What is the role of UHC in KPLHS? Does UHC only provides free services in hospitals and not in KPLHS?

Page 18-19, lines 341-357 - The authors did a good job providing a comprehensive list of limitations. They could consider also providing their insights on: (1) limitations on the coding of qualitative into quantitative data as I assumed it precluded more robust means of comparing proportions like chi-square; (2) information bias, if applicable

Page 18, lines 344-350 - Could this also be self-selection bias? It is a very common form of bias among volunteer samples. Apart from the response rates, were there any responses that were terminated in between responding, leading to attrition of respondents and high missing values?

Conclusions

In general: Conclusions are supported by the findings.

Page 19, lines 359-367 - I would recommend the authors to also provide their insights (also applies in the discussion part) on how KPLHS fits in the larger picture of UHC. From reading this manuscript, the systems wherein the KPLHS and hospitals operate seem to be very separate. The spirit of UHC is towards integrating service delivery. Moreover, a big issue in KPLHS is sustainability especially if donor funding would decrease. Is UHC key to sustainability of KPLHS? I would be interested to hear the insights of our authors on this point.

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19 Mar 2022

MS: PONE-D-21-31678R1

"A Comparison of Attitudes and Knowledge of pre-exposure prophylaxis (PrEP) between hospital and Key Population Led Health Service providers: Lessons for Thailand’s Universal Health Coverage implementation"

Date 10 March 2022

Benjamin R. Bavinton, PhD, MPH, BA (Hon)

Kirby Institute, University of New South Wales

Level 6, Wallace Wurth Building

High Street, UNSW Sydney

Kensington NSW 2052

Academic Editor

PLOS ONE

Dear Dr. Benjamin R. Bavinton,

On behalf of all authors, thank you for considering our manuscript and we would like to thank editors and reviewers for their comments, and the opportunity to revise our manuscript entitled "A Comparison of Attitudes and Knowledge of pre-exposure prophylaxis (PrEP) between hospital and Key Population Led Health Service providers: Lessons for Thailand’s Universal Health Coverage implementation” (PONE-D-21-31678).

We have made revisions in response to the insightful reviewers’ comments. In the response to referees’ letter, we provide point-by-point responses to all comments from the two reviewers together with the revised manuscript in tracked changes and clean version.

We have neither financial nor non-financial competing interest. All authors having contribution met criteria for authorship. We attest that this work is original and has not been published and is not being considered for publication elsewhere. Please feel free to contact me with additional questions or concerns.

Point-by-point responses to all comments are as follows:

Responses to Reviewers

"A Comparison of Attitudes and Knowledge of pre-exposure prophylaxis (PrEP) between hospital and Key Population Led Health Service providers: Lessons for Thailand’s Universal Health Coverage implementation" (PONE-D-21-31678).

Reviewer comments: Method

Reviewer #1 (Comments to the Author):

1. Overall, research method is somewhat questionable and can easily introduce the bias to interpret the study and make the whole study not valid. The number of participants were small and skewed towards people from KPLHS. I would suggest authors to describe the temporal trends of the PrEP uptake in Thailand to see a clearer picture and compare whether KPLHS in other countries do provide PrEP in the same manner as in Thailand.

Response #1

Thank you for this valuable comment. The study included all PrEP service providers from 50 active PrEP centers under the National Health Security Office (NHSO)’s pilot project in 2020, of which there were 46 hospitals and 4 KPLHS. The number of respondents from KPLHS is small compared to those from hospitals as most participating centers are from hospital settings. The information derived was based on the reality which we believe will provide important insights regarding knowledge of, and attitudes among providers who have engaged in PrEP services.

The temporal trend of the PrEP uptake in Thailand as well as PrEP service at KPLHS setting in other countries have already been mentioned in the introduction and discussion sections of the manuscript as the followings.

Original version

None

Revised version (lines 90-92, and lines 340-349)

Lines 90-92

The cumulative number of PrEP users in Thailand has been increasing substantially from 1,865 in 2017 to 13,769 in 2021, of which KPLHS accounted approximately two-third of PrEP services [16].

Lines 340-349

The first PrEP demonstration project at seven KP-friendly clinics in the Democratic Republic of the Congo showed high uptake and acceptability among KP clients [34] whereas a study from a gay-friendly MSM HIV/STI clinic in Sweden revealed that targeting high-risk population with HIV risk individuals such as MSM was highly effective and could significantly reduce the long-term HIV prevalence [35]. KPLHS is also the main component of PrEP service delivery model in Vietnam [8]. The service includes integrated home lab sample collections and HIV testing along with telehealth and courier PrEP delivery during the COVID-19 pandemic [8]. Consistently, the key population-led PrEP program demonstration project was successfully completed in the Philippines and the country is moving forward towards the national implementation [8].

2. Page 6, line 131. How many missing values were excluded from the analysis? Did that create a bias?

Response #2

There was one missing value for the item concerning PrEP service experiences in one respondent from hospital setting as shown in Table 2, line 166, page 8. This is unlikely to create any bias or impact the study results.

3. Page 6, line 136-138 and Page 18 Line 343-346. Please explain why more people per KPLHS responded more than per hospital? Is there any incentive to answer the questionnaire? Why did the research team choose these 4 KPLHS? Do they provide more PrEP services than the hospitals?

Response #3

Each participant was compensated with 100 Thai baht (approximately 3 US$) for their time. The reason that there were more respondents per KPLHS than per hospital might be because PrEP service at hospital setting is usually integrated with ARV and STI clinics of which few staff were assigned to be particularly responsible for PrEP service whereas PrEP service is the primary focus with more dedicated staff at KPLHS setting. We chose all active PrEP centers under the National Health Security Office (NHSO)’s pilot project in 2020, of which there were 46 hospitals and 4 KPLHS as mentioned in the introduction of the manuscript (lines 84-86 in the original version, lines 93-95 in the revised version).

4. Page 7, line 148. Please explain what is traditional physician and provide more detail about the right to prescribe PrEP by traditional physician in Thailand.

Response #4

Traditional physician and other non-HCPs provide PrEP counselling. The prescriptions are provided by physicians. The definition of traditional physician has been added for clarity as follows:

Original version (lines 112-113)

“, pharmacist, and traditional physician”.

Revised version (line 159-160)

“, pharmacist, and traditional physician, a licensed practitioner of Thai traditional medicine from the Thai Traditional Medical Council [21]”.

5. Page 11, Line 171. Unclear if the title is completed.

Response #5

The title “The evidence based” refers to attitude towards PrEP in terms of the evidence based as described in the method section lines 106-108 and the results section lines 173-175 as below:

Lines 108-110

“The second part entails attitudes towards PrEP service in terms of the evidence base, experiences, prioritization, effectiveness among risk groups, required support from NHSO/MoPH, and provision.”

Lines 176-178

Table 3 and Figure 2 present overall service providers’ attitudes to PrEP in terms of the evidence base, service delivery experiences, prioritization, effectiveness among risk groups, required support from NHSO/MoPH, and provision.

6. Page 13, Line 225. I would suggest to add these answers to the background or discussion. What kind of training and how often the training occur currently? Any particular certificates needed prior to be PrEP providers?

Response #6

PrEP training for service providers is usually conducted annually by Division of AIDS and STIs, Department of Disease Control, Ministry of Public Health, Thailand. The curriculum includes update on HIV treatment and prevention, the use of PrEP and its potential side effects, PrEP counselling, PrEP database and recording. Currently, there is no official certificate for PrEP providers. The discussion section has been revised to include details of PrEP training as follows:

Original version (lines 294-296)

Therefore, equipping KPLHS lay providers through systematic training and up-to-date information concerning TGW’s health concerns would be essential in enhancing PrEP uptake and retention.

Revised version (lines 310-313)

Therefore, there is a need for more specific training concerning TGW’s health concerns in addition to regular annual PrEP training by MoPH which usually entails PrEP use, potential side effects, and counselling to equip KPLHS lay providers in enhancing PrEP uptake and retention.

Reviewer #2 (Comments to the Author):

1. Introduction

In general: Kindly consider providing context on the state of the UHC implementation in Thailand (particularly, whether PrEP is considered a public-level intervention that the cost of which will be covered by the government). Could also consider clarifying describing the role of KPLHS in the primary care setting amid the UHC - i.e., does it receive funding from the government, does it heavily depend on donor funding? Lastly, could consider providing information whether PrEP is accessible for free or at-cost.

Response #1

Thank you for your valuable comment. The information of PrEP in the context of the UHC implementation as well as the role of KPLHS has been provided as follows.

Original version (lines 66-68), (lines 77-78)

Lines 66-68

In Thailand, PrEP has been included in the National Guidelines on HIV/AIDs Treatment and Prevention as an additional measure among high-risk populations since 2014 [7]

Lines 77-78

The KPLHS model was established in 2015 in response to the needs of the key populations [10, 11] at risk for HIV.

Revised version (lines 66-69), (lines 77-83)

Lines 66-69

In Thailand, PrEP has been included in the National Guidelines on HIV/AIDs Treatment and Prevention by the Ministry of Public Health (MoPH) as an additional measure among high-risk populations since 2014 [7] and become available free of charge under the Universal Health Coverage (UHC) since 2019 [8].

Lines 77-83

The KPLHS model was established in 2015 in response to the needs of the key populations [10, 11] at risk for HIV. A defined set of HIV-related health services is provided at KPLHS clinics which are in close proximity to key population communities [12]. The main source of fundings for KPLHS is largely from non-government organizations. The first KPLHS program for marginal population was supported by the Princess Soamsawali HIV Prevention fund under the Thai Red Cross AIDS Research Center of which PrEP services were provided in eight clinics in four provinces (Bangkok, Chonburi, Chiang Mai and Songkhla) [13].

2. Kindly consider changing from "AIDs" to "AIDS"

Response #2

The term “AIDs” has already been changed to “AIDS” throughout the manuscript.

3. Page 3, line 58-59 - Could the authors clarify if this is AIDS epidemic, endemic, or pandemic?

Response #3

Thank you for pointing this out. “AIDS endemic” has been changed to “AIDS epidemic” as below:

Original version (lines 58-60)

To achieve the country’s ambitious goal in stopping the AIDS endemic by 2030, a number of strategies including scale-up screening for early HIV treatment and HIV prevention are required to pave the way for disease eradication.

Revised version (lines 58-60)

To achieve the country’s ambitious goal in stopping the AIDS epidemic by 2030, a number of strategies including scale-up screening for early HIV treatment and HIV prevention are required to pave the way for disease eradication.

4. Methods

Page 4, line 93: There was no adequate description of the study settings, especially how KPLHS fit into the larger picture of UHC implementation in Thailand.

Response #4

A detailed description of KPLHS model and KPLHS under, the National Health Security Office (NHSO)’s pilot project for PrEP scale up under the UHC has already been mentioned in the introduction and results sections including the followings:

Original version (lines 76-77), (lines 136-137)

Lines 76-77

The KPLHS model was established in 2015 in response to the needs of the key populations [10, 11] at risk for HIV.

Lines 136-137

The four KPLHS were Rainbow Sky Association of Thailand, Service Workers in Group, MPlus, and Caremat.

Revised version (lines 77-83), (lines 144-148)

Lines 77-83

The KPLHS model was established in 2015 in response to the needs of the key populations [10, 11] at risk for HIV. A defined set of HIV-related health services is provided at KPLHS clinics [12] which are in close proximity to key population communities. The main source of fundings for KPLHS is largely from non-government organizations. The first KPLHS program for marginal population was supported by the Princess Soamsawali HIV Prevention fund under the Thai Red Cross AIDS Research Center of which PrEP services were provided in eight clinics in four provinces (Bangkok, Chonburi, Chiang Mai and Songkhla) [13].

Lines 144-148

The four KPLHS were Rainbow Sky Association of Thailand (RSAT), Service Workers in Group (SWING), MPlus, and Caremat. MPlus delivers PrEP service on behalf of Nakornping hospital while PrEP service at SWING, RSAT and Caremat was operated on behalf of the Thai Red Cross AIDS Research Center (Anonymous Clinic).

5. Page 4, line 98 - Bisexual is not gender but a sexual orientation. Gender indentity can be cis-gender, transgender, or non-binary. Sexual orientation includes homosexual, bisexual, and etc. Moreover, TGW can self-identify as homosexual, bisexual, and etc.

Response #5

The phrase has been revised from current gender to be current gender/sexual orientation as below:

Original version (lines 97-98)

“current gender (gay, bisexual, TGW, other),….”

Revised version (lines 105-106)

“current gender/sexual orientation (gay, bisexual, TGW, other),….”

6. Page 5, line 101 - NHSO should be spelled out.

Response #5

The term NHSO is already spelled out when it is mentioned for the first in the introduction section line 93 as below:

Lines 93-95

To ensure sustainable service delivery, the National Health Security Office (NHSO) launched a pilot project in 2020 to provide PrEP for 2,000 new clients at 50 PrEP service centers (46 hospitals and 4 KPLHS) across the country.

7. Page 5, line 105 - when we say "in comments", do the authors mean qualitatively? This could be clarified further. Moreover, it could be clarified whether how the "first three" were collected - were these based on the first three that come into the participants' minds or based on necessity?

Response #7

The first three supports required in PrEP service were collected in the online survey as an open-ended question that respondents can write down the top three priorities regarding PrEP service in their opinion. We have revised the sentence to be clearer as follows:

Original version (lines 104-105)

The third part inquires about the first three supports required from NHSO/MoPH regarding PrEP service in comments.

Revised version (line 112-113)

The third part inquires about the first three supports required from NHSO/MoPH regarding PrEP service in comments based on their opinion.

8. Page 5, line 113 - The authors could consider removing the definition of QR code for brevity.

Response #8

We are not convinced that all of the readers will be familiar with QR code, and it is a very important tool for this research. Therefore, upon discussion with all authors, we agree that it will be helpful to keep its definition.

9. Page 5, line 113-121 - Sampling technique was not discussed. The authors could further explain the technique and calculations, if necessary. Inclusion and exclusion criteria for participants were not explicitly stated.

Response #9

There is no need to calculate the sample size as the study aimed to include all population of interest who are PrEP service providers from 50 active PrEP centers under the National Health Security Office (NHSO)’s pilot project in 2020. We have obtained respondents from all 50 active PrEP centers under NHSO. Through support from the NHSO and the national PrEP working committee in reaching all potential participants, we believe that all or almost all PrEP service providers who have engaged in PrEP service under the NHSO’s pilot project have already been included.

10. Page 7, line 148 - Can the authors clarify what a "traditional physician" is?

Response #10

The description of a traditional physician has been added as below:

Original version (line 148)

“.., pharmacist, and traditional physician.”

Revised version (lines 159-160)

“.., pharmacist, and traditional physician, a licensed practitioner of Thai traditional medicine from the Thai Traditional Medical Council [21]”.

11. Results

Page 7, Table 1 - Can the authors clarify the purpose of the variable "current gender"? I am aware that it is challenging to classify participants based on SOGIE but it is recommended that the decision on classification would depend on the research question. As mentioned in the earlier comment, sexual orientation and gender identity are 2 different concepts that TGW can identify themselves as lesbians or gay, as well. Hence, I would recommend revisiting this variable and putting the research question at heart. If it was only intended to illustrate that the KPLHS services were mostly facilitated by KP (cisgender MSM and TGW), then mentioning "KP group", with classifications such as (1) cis-MSM, (2) TGW, and (3) heterosexual male and female, would I think be suffice. See table in https://doi.org/10.1016/S2352-3018(18)30148-6 as an example.

Response #11

Although KPLHS services were mostly facilitated by KP, we can see that most providers identified themselves as gay, followed by TGW. This is also in line with the country’s PrEP uptake among KP that majority are MSM, followed by TGW. In the Thai context, only males who have undergone a surgery and have a female gender identity would identify themselves as TGW whereas MSM still have male appearance with homosexual orientation. We believe that categorization things this way would provide more insights and more relevant to the Thai context which is unlikely to result in any error of the study findings.

12. Page 7, line 150-152 - The way the authors explained the context at KPLHS was commendable. I would suggest putting this in the main text rather than a table caption.

Response #12

The context at KPLHS had been clearly explained previously in the introduction and results sections including the followings:

Introduction, lines 84-87

PrEP is provided by lay providers who are often members of the key populations under a “needs-based, demand-driven, and client-centred” approach in close collaboration with the public health sector to ensure friendly and respectful service access [10, 14].

Results, lines 157-158

The majority of service providers at KPLHS were reported as trained and qualified lay PrEP counsellors who did not hold any HCP license (35 of 38; 92.11%) while one each was a nurse,….

13. Discussion

Page 15-16, lines 263-279 - I commend the authors providing insight in the KPLHS. It is indeed key to addressing the disproportionate increase in HIV incidence among KP in Thailand. However, it could also be interesting if there were insights on the hospitals as PrEP providers and the integration of the KPLHS in the primary care setting amid the UHC. Discussions like these have to be started, especially as many low- and middle-income countries are transitioning towards the UHC and that donor funding in HIV is decreasing.

Response #13

Thank you for this helpful comment. Additional insights concerning the integration of KPLHS under the UHC has been included in the discussion as follows:

Original version

None

Revised version (lines 292-295)

Although KPLHS have been legalized for PrEP provision in Thailand, KPLHS clinics have not been certified and cannot be reimbursed directly from the NHSO. Therefore, the funding mechanism for differentiated service delivery models to facilitate integration of KPLHS under the UHC is key to ensure sustainability and high coverage among KP.

14. Page 16, lines 281-296 - Pretty good insight on the attitudes of providers. Do the authors likewise think that their attitudes might be influenced by their clientèle profile? It would be interesting to note whether hypothetically most of the MSM and TGW are being provided PrEP in the KPLHS, whereas sex workers are mostly accessing in the hospital. Is there such data in Thailand that could provide insights on this?

Response #14

Yes, we had previously noted our limitation that “The difference of respondents’ characteristics between hospital and KPLHS settings might influence attitudes towards PrEP. The fact that most KPLHS providers are members of key population communities would probably have affected the results with slightly more positive attitudes about PrEP compared to hospital settings.” Lines 382-386. The number of people who identified themselves as sex workers using PrEP service in Thailand is very small from both hospital and KPLHS settings1.

1 Chariyalertsak S, Chautrakarn S, Intawong K, Rayanakorn A, Chariyalertsak C, Khemngern P, et al. HIV pre-exposure prophylaxis monitoring and process evaluation for Thailand’s National PrEP roll-out under the Universal Health Coverage (UHC) for fiscal year 2020. Faculty of Public Health, Chiang Mai University: Faculty of Public Health, Chiang Mai University; 2021.

15. Page 16, lines 292-293 - Negative attitude on effectiveness of PrEP on TGW among hospital providers was higher than in the KPLHS. I really commend the authors for emphasizing this as based on Figure 2, it seems that there was a disproportionately higher negative attitude among hospital providers specifically to this. The authors could also reconsider hospitals being sensitized or trained on transgender-related health issues and not only rely on KPLHS for service delivery. Conversely, this could open discussions for the attitudes of TGW among hospital providers and their preference for KPLHS. Nonetheless, I think there is always benefit in investigating this point further.

Response #15

Thank you for highlighting this point. Higher negative attitude on effectiveness of PrEP on TGW among hospital providers has already been discussed as follows:

Original version

None

Revised version (lines 313-318)

The reason that hospital providers showed higher negative attitude concerning effectiveness of PrEP among TGW was probably due to their limited experiences among TGW population. Hence, sensitizing or training on transgender-related health issues focusing on service provision tailored at individual level should also be considered to improve the capacity among hospital providers to advise clients with specific needs.

16. Page 17, lines 307-316 - Great insights!

Response #16

Thank you very much.

17. Page 18, lines 338-340 - More context is needed here. What is the role of UHC in KPLHS? Does UHC only provides free services in hospitals and not in KPLHS?

Response #17

The information of KPLHS under the UHC has already been described in the manuscript including the followings:

Lines 77-83

The KPLHS model was established in 2015 in response to the needs of the key populations [10, 11] at risk for HIV. A defined set of HIV-related health services is provided at KPLHS clinics [12] which are in close proximity to key population communities. The main source of fundings for KPLHS is largely from non-government organizations. The first KPLHS program for marginal population was supported by the Princess Soamsawali HIV Prevention fund under the Thai Red Cross AIDS Research Center of which PrEP services were provided in eight clinics in four provinces (Bangkok, Chonburi, Chiang Mai and Songkhla) [13].

Lines 144-148

The four KPLHS were Rainbow Sky Association of Thailand (RSAT), Service Workers in Group (SWING), MPlus, and Caremat. MPlus delivers PrEP service on behalf of Nakornping hospital while PrEP service at SWING, RSAT and Caremat was operated on behalf of the Thai Red Cross AIDS Research Center (Anonymous Clinic).

Lines 292-295

Although KPLHS have been legalized for PrEP provision in Thailand, KPLHS clinics have not been certified and cannot reimburse directly from the NHSO. Therefore, the funding mechanism for differentiated service delivery models to facilitate integration of KPLHS under the UHC is key to ensure sustainability and high coverage among KP.

18. Page 18-19, lines 341-357 - The authors did a good job providing a comprehensive list of limitations. They could consider also providing their insights on: (1) limitations on the coding of qualitative into quantitative data as I assumed it precluded more robust means of comparing proportions like chi-square; (2) information bias, if applicable

Response #18

The first three supports required in PrEP service were collected in the online survey where respondents can provide a short answer regarding the top three priorities regarding PrEP service in their opinion. The question and responses were very straightforward. The authors checked and reviewed all the responses provided and only put similar responses into the same categories for descriptive analysis. Therefore, this is unlikely to result in any potential bias.

19. Page 18, lines 344-350 - Could this also be self-selection bias? It is a very common form of bias among volunteer samples. Apart from the response rates, were there any responses that were terminated in between responding, leading to attrition of respondents and high missing values?

Response #19

To our knowledge, there was no response being terminated. There were only few duplicate responses due to multiple submissions from the same respondents which had been identified and removed during data cleaning before the analyses. There was only one missing value which is unlikely to have any impact on the study findings.

20. Conclusions

In general: Conclusions are supported by the findings.

Page 19, lines 359-367 - I would recommend the authors to also provide their insights (also applies in the discussion part) on how KPLHS fits in the larger picture of UHC. From reading this manuscript, the systems where in the KPLHS and hospitals operate seem to be very separate. The spirit of UHC is towards integrating service delivery. Moreover, a big issue in KPLHS is sustainability especially if donor funding would decrease. Is UHC key to sustainability of KPLHS? I would be interested to hear the insights of our authors on this point.

Response #20

We appreciate the reviewer for bringing this important point. This point has already been addressed in the manuscript including the sentences below:

Revised version (lines 292-295)

Although KPLHS have been legalized for PrEP provision in Thailand, KPLHS clinics have not been certified and cannot be reimbursed directly from the NHSO. Therefore, the funding mechanism for differentiated service delivery models to facilitate integration of KPLHS under the UHC is key to ensure sustainability and high coverage among KP.

Please refer to the response of question number 17 for further details.

Yours sincerely,

Ajaree Rayanakorn and behalf of all authors

Ajaree Rayanakorn, B.Pharm, MPH, Ph.D

Faculty of Public Health, Chiang Mai University

Chiang Mai 50200, Thailand

Email: ajaree.rayanakorn@cmu.ac.th

Tel: 66 5 394 2519

Fax: 66 5 392 2525

Submitted filename: Responses to Reviewers_1.docx

Click here for additional data file.

29 Apr 2022

A Comparison of Attitudes and Knowledge of pre-exposure prophylaxis (PrEP) between hospital and Key Population Led Health Service providers: Lessons for Thailand’s Universal Health Coverage implementation

PONE-D-21-31678R1

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Reviewer #2: Thank you for responding to all the comments. I think all the responses were comprehensive and the current manuscript reflects significant changes. While I believe that the current form is worthy of publication, I would encourage the authors to be more explicit with the sampling technique. I do acknowledge that no power calculations have been done, but it is likely that a non-probabilistic sampling has been used (i.e., maybe convenience sampling). Various reporting guidelines recommend stating the sampling technique utilized. Nonetheless, I have no further suggestions. Good luck to the authors!

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Reviewer #1: Yes: Rapeephan Rattanawongnara Maude

Reviewer #2: Yes: Patrick Eustaquio

4 May 2022

PONE-D-21-31678R1

A Comparison of Attitudes and Knowledge of pre-exposure prophylaxis (PrEP) between hospital and Key Population Led Health Service providers: Lessons for Thailand’s Universal Health Coverage implementation

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