Sima Barmania 最近的專題報導《泰國愛滋病毒應對措施的成功與挑戰》質疑泰國公共衛生部支持社區主導的愛滋病毒服務的承諾。報告指出,「公共衛生部的新指南撤銷了非專業人士對[暴露前預防] PrEP 的授權」,並提出了兩項新要求——「只有政府醫生才能開PrEP 處方」和「重點人群——社區主導的診所不能儲備PrEP 藥物」—這對社區主導的診所構成了真正的威脅。 2019 年,公共衛生部發布了三項部級法規,允許經過認證的社區衛生工作者在衛生專業人員的監督下提供愛滋病毒服務。法規允許社區衛生工作者篩選愛滋病毒並向需要的人提供抗反轉錄病毒藥物處方,而此前從未允許非醫務人員這樣做。這些變化反映了公共衛生部讓民間社會參與並參與提供愛滋病毒服務的承諾。
2023 年,公共衛生部發布了為民間社會組織(社區主導組織)提供 PrEP 服務的指南。該指南旨在透過與政府衛生機構的服務配對來整合民間社會組織。不過,該指引並沒有限制私人醫生在私人診所開立PrEP處方。透過這種配對模式,民間社會組織可以透過遠距醫療服務在專業監督下開展工作,提供諮詢、篩選,並在民間社會組織處庫存處方 PrEP,然後再交付給 PrEP 接受者。
然而,註冊為醫療技術診所的社區主導診所有其限制。這些診所必須遵守《醫療設施法》、B.E. 2541 (1998) 和《醫療技術職業法》,B.E. 2547 (2004),僅允許這些診所對醫學標本的檢查進行實驗室調查、分析、研究和報告。
對「泰國支持社區主導的愛滋病毒服務的承諾」一文的回應
Cheewanan Lertpiriyasuwat 及其同事認為,泰國公共衛生部於2019 年發布了三項部級法規,承諾讓民間社會作為參與愛滋病毒服務之提供者,這些法規允許經過認證的社區衛生工作者在衛生部門的專業人士監督下提供愛滋病毒服務。這項行動確實值得讚揚,因為民間社會和政府之間實現正式夥伴關係的過程是一個漫長的過程,其共同目標是在泰國消除愛滋病。然而,公共衛生部2023 年的在社區主導設施中的暴露前預防 (PrEP) 服務提供指南,旨在透過與政府衛生設施的服務配對來整合民間社會組織,無意中對泰國具有成本效益、重點人群主導的當日PrEP 服務產生了不利影響。泰國流行病學數據顯示,在指南實施 3 個月後,接受 PrEP 的新顧客數量減少了 21%,而前幾季則呈現 11-12% 的上升趨勢。這是該指南的負面影響,因為它不僅不允許非政府醫生在重點人群主導和社區主導的 PrEP 服務提供中開具 PrEP 處方,而且還阻止重點人群主導和社區主導的診所在PrEP 藥物上的儲備。
我們認為,讓非政府醫生參與以重點人群為主導的PrEP 服務提供上至關重要,因為在過去8 年裡,找到足夠多的政府醫生,且他們願意在重點人群主導的診所為客戶開PrEP 處方一直是一項挑戰。因此,大多數以重點人群為主導的診所都與非政府醫生建立了富有創意且有價值的合作夥伴關係,這些醫生為接受 PrEP 的顧客進行電話處方。正如 Lertpiriyasuwat 及其同事所說,非政府或私人醫生仍然可以在私人診所開立 PrEP 處方,但他們不能在重點人群主導的診所開處方,即使他們沒有獲得此類服務的任何報酬。
自2023年起,衛生部指引不允許重點族群主導的診所儲備PrEP藥物;他們的診所工作人員現在需要花費額外的時間和資源從配對的政府醫院領取單獨包裝的 PrEP 藥物,並確保藥物準備好分發給每天安排的顧客。這指引不必要地使新顧客或計畫外顧客不再能夠在重點人群主導的診所提供當天的 PrEP 服務。
為了讓其服務得到國家衛生保障辦公室的正式認可和報銷,重點人群主導的診所被註冊為醫療技術診所。 Lertpiriyasuwat 和同事提到,這些診所只被允許進行實驗室檢查。如果公共衛生部將此聲明轉化為指導方針,那些希望擴大 PrEP 規模的人將會感到進一步的沮喪,特別是因為在泰國使用 PrEP 的人超過 80% 正在以重點人群為主導場域接受服務。我們想提醒公共衛生部,2019 年的部級法規最初允許訓練有素且經過認證的社區衛生工作者提供某些愛滋病毒服務,以加速泰國愛滋病的終結。現在放棄這一大膽的進步這將是一種倒退。
我們聲明不存在競爭利益。
*Nittaya Phanuphak、Surang Janyam、Pongpeera Patpeerapong、Satayu Sittikan、Kittinan Daramadhaj、Supabhorn Pengnonyang、Rena Janamnuaysook、Inthira Suya、Stephen Mills、Praphan Phanuphak nittaya.p@ihri.org
愛滋病毒研究與創新研究所,曼谷 10330,泰國(NP、SP、RJ、PPh); Service Worker In Group Foundation,泰國曼谷(SJ); 泰國愛滋病非政府組織聯盟,泰國曼谷(SJ); MPLUS 基金會,泰國清邁 (PPa); Caremat 基金會,泰國清邁(SS); 泰國彩虹天空協會,泰國曼谷 (KD); FHI 360, 曼谷, 泰國 (IS, SM)
Thailand’s commitment to support community led HIV services
Sima Barmania’s recent feature story, Successes and challenges in Thailand’s HIV response, questioned the Thailand Ministry of Public Health’s commitment to support community led HIV services. The report stated that “the new guidelines by the Ministry of Public Health revoke authorisation of [pre-exposure prophylaxis] PrEP by lay people” and that two new requirements—which were “only government doctors can prescribe PrEP” and “key-population-led clinics cannot stock PrEP medicine”—pose a real threat to community-led clinics. In 2019, the Ministry of Public Health issued three ministerial regulations that permitted certified community health workers to provide HIV services under the supervision of health professionals. These regulations allowed community health workers to screen for HIV and to give prescribed antiretrovirals to those who need them, which non medical personnel had never been permitted to do before. These changes reflect the Ministry of Public Health’s commitment to enable and engage civil society in the provision of HIV services.
In 2023, the Ministry of Public Health issued a guideline on PrEP service delivery for civil society organisations (community led organisations). The guideline aimed to integrate civil society organisations through service pairing with government health facilities. However, the guideline did not limit private doctors to prescribe PrEP at private clinics. With this pairing model, civil society organisations can work under professional super vision through telehealth services, offer counselling, screening, and stock prescribed PrEP at civil society organisations before delivery to PrEP recipients.
However, there are limitations for community-led clinics that are registered as medical technology clinics. These clinics must comply with the Medical Facilities Act, B.E. 2541 (1998) and the Medical Technology Profession Act, B.E. 2547 (2004), which only permit these clinics to do laboratory investigations, analysis, research, and report on the examination of medical specimens.
We declare no competing interests.
Cheewanan Lertpiriyasuwat, *Suchada Jiamsiri, Plearnpit Prommali sjiamsiri@outlook.com
Division of AIDS and STIs, Department of Disease Control, Ministry of Public Health, Nonthaburi 12000, Thailand
Response to Thailand’s commitment to support community-led HIV services
Cheewanan Lertpiriyasuwat and colleagues1 argue that Thailand’s Ministry of Public Health made a commitment to enable and engage civil society in HIV services as providers by the issuance in 2019 of three ministerial regulations, which permitted certified community health workers to provide HIV services under the supervision of health professionals. This action is truly commendable as it had been a long process to achieve formalised partnerships between civil society and government with the mutual goal of ending AIDS in Thailand. However, the Ministry of Public Health’s 2023 guideline on pre exposure prophylaxis (PrEP) service delivery at community-led facilities, with the intention to integrate civil society organisations through service pairing with government health facilities,1 inadvertently and detrimentally affected Thailand’s cost-effective, key-population-led, same-day PrEP service. EpiC Thailand data reveal a 21% decrease in the number of new clients receiving PrEP after 3 months of guideline implementation, given an 11–12% upward trend in previous quarters. This is a negative effect of the guideline as it not only disallows non-government doctors to pre scribe PrEP in key-population-led and community-led PrEP service delivery but also prevents PrEP medication to be stocked at key-population-led and community-led clinics.
We believe that it is crucial to engage non-government doctors in the key population-led PrEP service delivery because over the past 8 years finding enough government doctors who feel comfortable enough to prescribe PrEP for clients at key-population led clinics has been challenging. Therefore, most key-population-led clinics have made creative and valuable partnerships with non-government doctors who perform tele prescription for clients receiving PrEP. As stated by Lertpiriyasuwat and colleagues, non government or private doctors can still prescribe PrEP at private clinics, but they cannot do so at key-population led clinics even though they do not receive any reimbursement for such services.
Since 2023, the Ministry of Public Health’s guideline does not allow PrEP medication to be stocked at key-population-led clinics; their clinic staff now need to spend extra time and resources travelling to pick up individually packed PrEP medication from their paired government hospitals and to make sure that the medication is ready to be distributed to clients scheduled each day. The guideline unnecessarily made same-day PrEP service delivery at key-population-led clinics no longer possible for new or unscheduled clients.
To allow their services to be formally accredited and reimbursed by the National Health Security Office, key-population-led clinics are registered as medical technology clinics. Lertpiriyasuwat and colleagues mentioned that these clinics are only permitted to do laboratory investigations. If the Ministry of Public Health translates this statement into its guideline, further frustration will be caused for those wanting to see PrEP scaled up, especially since more than 80% of people who use PrEP in Thailand are receiving services at key-population-led clinics. We would like to remind the Ministry of Public Health that the 2019 ministerial regulations originally allowed well trained and certified community health workers to perform certain HIV services to accelerate the ending of AIDS in Thailand. To now move away from that bold advance would be a step backwards.
We declare no competing interests.
*Nittaya Phanuphak, Surang Janyam, Pongpeera Patpeerapong, Satayu Sittikan, Kittinan Daramadhaj, Supabhorn Pengnonyang, Rena Janamnuaysook, Inthira Suya, Stephen Mills, Praphan Phanuphak nittaya.p@ihri.org
Institute of HIV Research and Innovation, Bangkok 10330, Thailand (NP, SP, RJ, PPh); Service Worker In Group Foundation, Bangkok, Thailand (SJ); Thai NGO Coalition on AIDS, Bangkok, Thailand (SJ); MPLUS Foundation, Chiang Mai, Thailand (PPa); Caremat Foundation, Chiang Mai, Thailand (SS); Rainbow Sky Association of Thailand, Bangkok, Thailand (KD); FHI 360, Bangkok, Thailand (IS, SM)