Experiences and challenges of pre-exposure prophylaxis initiation and retention among high-risk populations: qualitative insights among service providers in Thailand.

Objectives: Pre-exposure prophylaxis (PrEP) has been an essential element of the national combination prevention package and included in the Universal Health Coverage (UHC) of Thailand since 2019. As a part of the national monitoring and evaluation framework, this qualitative study aims to describe experiences and barriers concerning PrEP initiation and retention among service providers from both hospital and Key Population Led Health Service (KPLHS) settings under the country's UHC roll-out. Methods: Between September and October 2020, ten focus group discussions with PrEP service providers from both hospitals and KPLHS across Thailand were conducted of which there were six hospitals, one health service center, three KPLHS. All interviews were recorded and transcribed verbatim to identify providers' experiences, attitudes, and perceived barriers regarding PrEP service delivery in Thailand. Results: Among the 35 PrEP service providers, most of them reported positive attitudes toward PrEP and believed that it is an effective tool for HIV prevention. Men who have sex with men were perceived to be the easiest group to reach while PrEP uptake remains a challenge in other key populations. Integration of a PrEP clinic with other HIV services at hospitals made most healthcare providers unable to adopt an active approach in recruiting new clients like at KPLHS settings. Challenges in delivering PrEP services included lack of public awareness, high workload, limited benefit package coverage, structural and human resources. Conclusion: Additional services to address different health needs should be considered to increase PrEP uptake among harder-to-reach populations. Novel approaches to PrEP service integration and close collaboration between hospitals and KPLHS would be essential in optimizing PrEP uptake and retention. Support regarding raising awareness, expanding service coverage and access, improving facilities and workforce, and providers' capacities are crucial for the success of the national PrEP programme.

Stigmatizing and discriminatory attitudes toward people living with HIV/AIDS (PLWHA) among general adult population: the results from the 6th Thai National Health Examination Survey (NHES VI).

Background: Thailand has an ongoing action plan to reduce human immunodeficiency virus (HIV) discrimination and stigma. We aimed to monitor the level of stigmatizing and discriminatory attitudes toward people living with HIV/AIDS (PLWHA) among the general adult population and to investigate its related factors. Methods: This study was based on data from the 6th Thai National Health Examination Survey, a large-scale country-wide survey in 2019-2020. We used a multistage sampling technique and included 11 843 adults aged 20 to 59. We collected data through face-to-face interviews which included six items related to HIV stigma domains. We weighted all analyses to account for the probability of sampling the Thai population aged 20 to 59 years. Results: We found that anticipated stigma had the highest percentage of negative stigmatizing attitude responses (78.5%), followed by perceived stigma (66.6%), fear of HIV infection (54.4%), and social judgment (28.2%). Regarding the UNAIDS global indicator for discriminatory attitude, 48.6% of respondents had negative perceptions to questions about experienced stigma or discrimination. Multiple logistic regression showed that factors associated with discriminatory attitudes toward PLWHA were being aged 20-39 (adjusted odds ratio (aOR) = 1.32, 95% confidence interval (CI) = 1.18-1.47) or 50-59 (aOR = 1.23, 95% CI = 1.09-1.40) compared to being aged 40-49, being Muslim compared to Buddhist (aOR = 1.73, 95% CI = 1.46-2.06), being married compared to being single (aOR = 1.15, 95% CI = 1.04-1.28), holding certificate degree or higher compared to not studying or studying at a primary level (aOR = 0.81, 95% CI = 0.68-0.97), living in the Northeast (aOR = 1.27, 95% CI = 1.12-1.45) and Bangkok (aOR = 1.30, 95% CI = 1.12-1.51) compared to living in the North, having no HIV/AIDS infected relative or acquaintance compared to having an HIV/AIDS infected relative or acquaintance (aOR = 1.56, 95% CI = 1.41-1.73), and not obtaining an HIV test compared to obtaining it (aOR = 1.10, 95% CI = 1.02-1.19). Conclusions: We found that HIV stigmatizing and discriminatory attitudes toward PLWHA decreased, but remained concerning among Thai adult people. A public education and awareness campaign, as well as an intervention to reduce HIV-related stigma and discrimination in the country's health care facilities, must still be maintained.

PrEP stigma among current and non-current PrEP users in Thailand: A comparison between hospital and key population-led health service settings.

Background: Pre-exposure prophylaxis (PrEP) has demonstrated effectiveness in high-risk populations. PrEP service in Thailand became free of charge under the Universal Health Coverage (UHC) in 2021. The National Health Security Office launched a pilot project in 2020 to ensure sustainable service delivery, and the national monitoring and evaluation (M&E) framework was adopted to evaluate early phase implementation. We carried out a cross-sectional survey as part of the M&E process to investigate PrEP stigma among current and non-current PrEP users from both hospital and Key Population Led Health Services (KPLHS) settings in Thailand. Methods: Between August and October 2020, an online cross-sectional survey was conducted. A link for a self-administered questionnaire was distributed to all active PrEP centers and PrEP clients were then recruited by PrEP providers. Descriptive and univariate analysis using Chi-square were applied in the analyses. Attitudes toward PrEP were ranked from the most negative to the most positive. The negative attitude can be interpreted as PrEP stigma. Results: This study included 513 PrEP clients (355 from hospitals and 158 from KPLHS). In both settings, respondents' attitudes toward PrEP were generally positive, but some potential stigma was observed. 31.8% of hospital PrEP clients and 9.5% of KPLHS clients agreed that PrEP users should keep their pills hidden from others. Almost half (44.5%) of hospital clients and 18.4% of KPLHS clients agreed that PrEP users are often viewed negatively by society. More than 20% of hospital clients and 12% of KPLHS agreed that PrEP users frequently experience difficulties when their partner/lover/family find out that he or she is on PrEP. Respondents from the hospitals had slightly higher PrEP stigma than those from KPLHS. Conclusions: According to our findings, at the policy level, the campaign to provide PrEP education to all groups of people should be continued in order to promote a positive view of PrEP and reduce PrEP-related stigma among the general population, which is critical for successful PrEP implementation.

The Influence of Family Caregiver Knowledge and Behavior on Elderly Diabetic Patients' Quality of Life in Northern Thailand.

The quality of life (QoL) of elderly diabetic patients may be affected by caregiver factors, but this has received little empirical support. The objective of this cross-sectional study is to determine the influence of family caregivers' diabetes knowledge and behavior on the QoL among elderly patients with diabetes mellitus (DM). The participants included 354 elderly patients with Type 2 DM and their family caregivers, who were recruited through multistage sampling from five districts in Chiang Mai, Thailand. Face-to-face interviews with DM patients were conducted using the Thai Simplified Diabetes Knowledge Scale (T-SDKS), the Thai version of the Diabetes Self-Management Questionnaire (DSMQ) for self-care behaviors, and the Thai version of the World Health Organization Quality of Life for Older People (WHOQOL-OLD) scale. For caregivers, their diabetes knowledge was measured by T-SDKS and patient-care or supportive behaviors were developed based on DSMQ. The results showed a moderate level of QoL among elderly diabetic patients. According to simple linear regression analysis, the QoL score among elderly DM patients was positively associated with their diabetes knowledge (B = 1.25), self-care behaviors (B = 3.00), caregivers' knowledge (B = 0.97), and supportive behavior from caregivers (B = 2.92) at a significance level of p < 0.01. In the multivariable model, patients' self-care behaviors (B = 1.58, p = 0.001), caregivers' knowledge (B = 0.58, p = 0.001), and patient-care behaviors (B = 1.38, p = 0.004) were significantly associated with QoL among DM patients when controlling for patient factors, including age, body mass index (BMI), education, and living arrangements, which accounted for 27.0% of the variance. This indicates that caregivers' adequate diabetes knowledge and appropriate supportive behaviors may impact the QoL of elderly diabetic patients. Health care providers should prioritize motivating and empowering family caregivers to pay more attention to the patient for the success goal.

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.

Self-Medication With Over-the-counter Medicines Among the Working Age Population in Metropolitan Areas of Thailand.

Background and Objectives: Self-medication with over-the-counter (OTC) medicines is becoming an increasingly popular practice around the world. The global prevalence rate of self-medication ranges from 11.2% to 93.7%, depending on the target population and country. However, there is a lack of data on the prevalence and practices of self-medication among the working-age population, particularly in Thailand metropolitan areas. The current study describes the prevalence of self-medication practices, adverse drug reactions and severity, reasons for self-medication, and basic medication knowledge among people of working age in metropolitan areas in Thailand. Methods: We conducted an online cross-sectional study between December 2020 and January 2021. Descriptive statistics were used to analyze self-medication data. A chi-square test was used to assess the association between self-medication and sociodemographic characteristics. Results: This study found high prevalence of self-medication among the working-age population in metropolitan areas of Thailand (88.2%). The most commonly used drug groups were NSAIDs (34.8%) and antibiotics (30.2%). Minor illness and easy access to pharmacies were the most common reasons for self-medication. Almost half of the participants' illnesses (42.6%) for which they self-medicated were not always completely cured, necessitating treatment at a hospital or clinic. Although only a small number of participants (ranged from 0.6 to 6.6%) experienced adverse drug reactions as a result of self-medication, some had severe symptoms that disrupted their daily lives or required hospitalization. In terms of basic medication knowledge, we discovered that study participants misunderstood some antibiotic drug concepts. Conclusions: According to the study findings, it is recommended that more information about the risks of self-medication, drug adverse reactions, antibiotic stewardship, more supervision of the prohibition of over-the-counter drugs and selling practices, and adequate facilities for peoples access to medical services be provided at the policy level.

High prescribing rates of third-generation cephalosporins in children hospitalized with acute lower respiratory infections at a university hospital.

OBJECTIVE: Antibiotics are frequently prescribed for the treatment of acute lower respiratory infections (ALRI) in children ≤5 years of age, even though viral aetiologies are the most common. The aim of this study was to describe antibiotic prescribing rates and patterns in children ≤5 years of age hospitalized with ALRI. METHODS: A retrospective study was conducted involving patients aged 1 month to 5 years hospitalized with ALRI at a university hospital. Patient demographics, ALRI diagnosis, microbiological data, antibiotics prescribed, and treatment outcomes were recorded and analysed. RESULTS: A total of 1283 patients were enrolled. Their median age was 1.6 years (interquartile range 0.8-2.8 years). Thirty-six percent had a co-morbidity. The diagnosis at discharge was viral ALRI in 81% and bacterial pneumonia in 19%. The mortality rate was 0.4%. The overall antibiotic prescribing rate was 46% (95% confidence interval 43-49%). Antibiotic prescribing rates were higher among children with co-morbidities (65% vs 35%, p < 0.001) and older children (57% for >2-5 years vs 39% for ≤2 years, p < 0.001). Parenteral third-generation cephalosporins were prescribed in up to 68% of all prescriptions. CONCLUSIONS: Nearly-half of hospitalized children with ALRI were prescribed antibiotics. The majority of prescribed antibiotics were third-generation cephalosporins. An antimicrobial stewardship programme and antibiotic guidelines should be implemented to promote the judicious use of antibiotics.

Antimicrobial prescription patterns in a tertiary-care pediatric unit in Thailand.

BACKGROUND: Antimicrobial resistance is one of the greatest public health threats worldwide. The improper prescription of antibiotics is one factor that promotes antibiotic resistance. Access to antimicrobial surveillance data is essential when assessing the pattern and appropriateness of antimicrobial prescriptions in hospitals and for the establishment of an antimicrobial stewardship program. This study aimed to describe the rate of antimicrobial use and the pattern of prescriptions in a tertiary care pediatric unit in Thailand. METHODS: A point prevalence survey on antimicrobial use was conducted monthly between January and June 2016, using standardized tools. The survey included all inpatient pediatric beds and identified all children receiving antimicrobial treatment on the day of the survey. RESULTS: The study included 644 children, 43.3% of whom received antimicrobial treatment during hospitalization. In general wards, the rate of antimicrobial prescriptions was 37.2%; in oncology wards it was 47.0%; in intensive care units it was 38.7%, and in surgical wards it was 67.7%. Meropenem was the most prescribed antimicrobial in the general wards (24.5%) and intensive care units (28.6%), whereas antipseudomonas was the most commonly prescribed antimicrobial in the oncology ward (26.6%). For the surgical ward, the most prescribed antimicrobial was third-generation cephalosporin for both prophylaxis and treatment (39.0%). The most common reason for antimicrobial use was the treatment of infections. CONCLUSIONS: Nearly half of hospitalized children received at least one antimicrobial. This was comparable with other pediatric tertiary care centers, although the high use of meropenem was different. This study provides important baseline information on antimicrobial use in a large tertiary-care pediatric unit and could lead to a nationwide survey in the future.

Impact of a Prospective Audit and Feedback Antimicrobial Stewardship Program in Pediatric Units in Tertiary Care Teaching Hospital in Thailand.

BACKGROUND: Antimicrobial stewardship programs (ASPs) have been proven to be beneficial in reducing the use of antimicrobial agents, antibiotic resistance, and health care costs. The data supporting the utility of ASPs has come largely from adult hospital units, but few pediatric hospital units have implemented ASPs. Our objective for this study was to assess the impact of ASPs in pediatric units in tertiary care teaching hospitals. METHODS: We conducted a retrospective chart review to compare antimicrobial use pre- and post-ASP over a 6-month period in a tertiary care hospital in which an ASP had been in use since July 2017. Meropenem, vancomycin, and colistin were selected to be monitored. ASP rounds were conducted twice a week to assess and provide feedback on antimicrobial prescriptions. Antimicrobial use was measured as days of therapy (DOTs) per 1000 patient-days and was compared pre- and post-ASP by using independent t tests. RESULTS: Charts of children hospitalized who were in antimicrobial treatment pre-ASP (44.3%) and post-ASP (41.7%) were reviewed. The percentages of children who received selected antimicrobial agents did not differ between pre- and post-ASP. During the post-ASP period, a significant reduction in DOT with vancomycin and colistin was observed. Vancomycin use decreased from 58.5 to 40.2 DOTs per 1000 patient-days (P = .038), and colistin decreased from 36.3 to 13.8 DOTs per 1000 patient-days (P = .026). Meropenem use decreased from 126.8 to 111.2 DOTs per 1000 patient-days (P = .467). Between the 2 periods, there was no effect on length of stay and mortality. CONCLUSIONS: ASPs can lead to a significant reduction in selected antimicrobial use in children who are hospitalized, with no effect on length of stay or mortality rate.

The impact of combination antiretroviral therapy and its interruption on anxiety, stress, depression and quality of life in Thai patients.

OBJECTIVE: Investigation on anxiety, stress, depression, and quality of life (QoL) within STACCATO, a randomised trial of two treatment strategies: CD4 guided scheduled treatment interruption (STI) compared to continuous treatment (CT). PARTICIPANTS: Thai patients with HIV-infection enrolled in the STACCATO trial. METHODS: Anxiety, depression assessed by the questionnaires Hospital Anxiety and Depression Scale (HADS) and DASS, stress assessed by the Depression Anxiety Stress Scale (DASS), and QoL evaluated by the HIV Medical Outcome Study (MOS-HIV) questionnaires. Answers to questionnaires were evaluated at 4 time-points: baseline, 24 weeks, 48 weeks and at the end of STACCATO. RESULTS: A total of 251 patients answered the HADS/DASS and 241 answered the MOS-HIV of the 379 Thai patients enrolled into STACCATO (66.2 and 63.6% respectively). At baseline 16.3% and 7.2% of patients reported anxiety and depression using HADS scale. Using the DASS scale, 35.1% reported mild to moderate and 9.6% reported severe anxiety; 8.8% reported mild to moderate and 2.0% reported severe depression; 42.6% reported mild to moderate and 4.8% reported severe stress. We showed a significant improvement of the MHS across time (p=0.001), but no difference between arms (p=0.17). The summarized physical health status score (PHS) did not change during the trial (p=0.15) nor between arm (p=0.45). There was no change of MHS or PHS in the STI arm, taking into account the number of STI cycle (p=0.30 and 0.57) but MHS significant increased across time-points (p=0.007). CONCLUSION: Antiretroviral therapy improved mental health and QOL, irrespective of the treatment strategy.