Using nominal group technique to identify and prioritize barriers to decentralizing HIV care to primary health...

Decentralizing HIV services is an evidence-based strategy recommended by the World Health Organization to expand healthcare access by shifting most HIV care from specialty (SHCs) to primary health centers (PHCs) with the goal of maximizing health outcomes. To accelerate Peru Ministry of Health's 2020 priority to transition from specialty to primary health centers, we assessed multilevel stakeholders' perspectives on barriers and opportunities for scaling-up decentralization of HIV care.

Between January and March 2024, we used nominal group technique (NGT), a mixed-methods research strategy, to rapidly identify barriers and rank potential solutions to decentralizing HIV services among two groups of patients (N = 16) and four groups of healthcare providers (N = 49) in Lima, Peru. Patient groups were those who: (1) were established in HIV care at a SHC; and (2) transferred from a SHC to a PHC. Three provider groups were mixed and included individuals from PHCs and SHCs while one was from a SHC in Central Lima. After listing all perceived barriers and solutions, participants in each group rank-ordered responses to generate potentially actionable responses.

Among 195 votes from 65 participants, multilevel HIV stigma was the highest priority barrier to decentralizing HIV care among both patients and providers (34.4%). While patients and providers prioritized different issues, all NGT groups highlighted a general lack of confidence in the expertise of PHCs (21.0%), system-level or transfer logistic challenges (19.0%), insufficient infrastructure and capacity of PHCs to provide HIV treatment (15.9%), and a lack of patient-level support (9.7%) as other major barriers to HIV decentralization.

While the Peruvian Ministry of Health has prioritized HIV care decentralization, achieving this goal remains challenging. Identified barriers require a range of implementation strategies to achieve decentralization goals, such as process improvement strategies to address stigma and logistical barriers to transferring patients, while educational meetings, including tele-mentoring or expert feedback, may address a lack of confidence in provider expertise at PHCs. Deployment of hub-and-spoke treatment models could enhance communication between experts at SHCs and PHCs and ensure that patient continuity of care is achieved.