Implementing Standardized HIV Care Clinics: A Qualitative Study from Healthcare Providers in Yunnan, China

Implementing Standardized HIV Care Clinics: A Qualitative Study from Healthcare Providers in Yunnan, China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementing Standardized HIV Care Clinics: A Qualitative Study from Healthcare Providers in Yunnan, China Yaling Zhang, Yuehua Zhang, Jincheng Lou, Tianshu Li, Xingqi Dong, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8586604/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background The global shift of HIV to a manageable chronic condition necessitates a transformation in care delivery from disease-centered approach to patient-centered, comprehensive management. In response, Yunnan Province has initiated the standardization of HIV care clinics. However, the frontline perspective on implementation remains a key gap, hindering insight into the real-world mechanisms of success and challenge. Methods This qualitative study was conducted in Yunnan Province, China, between March and June 2025. Using maximum variation purposive sampling, we recruited 28 participants (including physicians, and case managers) from five hospitals at the provincial, prefectural, and county levels. Data were collected through five semi-structured focus group discussions. The audio-recorded discussions were transcribed verbatim and analyzed using the Framework Method. Results This study identified four core domains in the implementation of standardized HIV clinics through framework analysis: (1) Restructuring Workflow and Environment, which enhanced service efficiency and quality through coordinated procedural, spatial, and digital reorganization; (2) Deepening Patient‑Provider Interaction, shifting care from transactional exchanges to patient‑centered, relational communication; (3) Building Organizational Support and Team Capacity, realized through leadership endorsement, experiential training, and flexible adaptation; and (4) Navigating Persistent Challenges, including resource constraints, differential adaptation among patients and staff, and unaddressed emotional labor burden. These domains are dynamically linked: structured workflows enable higher‑quality interactions, while the trust built through these interactions in turn refines workflow details. Organizational support reinforces this cycle, driving the establishment and sustainment of clinic standardization. Conclusions Yunnan’s standardized HIV care clinic model demonstrates that effective, sustainable chronic care emerges from the dynamic interplay of system rationalization and human empowerment, offering a replicable framework for similar settings while underscoring the need to address persistent resource and well-being challenges. HIV Care Clinic Standardization Qualitative Study Implementation China Figures Figure 1 Introduction The global scale-up of antiretroviral therapy (ART) has transformed HIV infection from a fatal disease into a manageable chronic condition [ 1 ]. This remarkable achievement has shifted the clinical paradigm and, consequently, the demands placed on healthcare systems. As life expectancy for people living with HIV (PLWH) approaches that of the general population, their health needs have evolved beyond virological suppression to encompass the holistic management of ageing-related comorbidities, mental health, and long-term quality of life [ 2 – 4 ]. This shift necessitates a corresponding transformation in service delivery models, from a narrow focus on medication dispensing to a broader, patient-centred approach that integrates chronic disease management, psychosocial support, and health promotion [ 5 – 7 ]. In response, health systems worldwide are re-evaluating and redesigning their HIV care services. The “treat-all” policy and the pursuit of the UNAIDS 95-95-95 targets have placed unprecedented volumes of patients into long-term care, straining existing clinic infrastructures [ 8 – 9 ]. Traditional, often fragmented and episodic, ART delivery models are increasingly recognized as inadequate for sustaining lifelong engagement and addressing the complex, multifaceted needs of a stable, ageing patient population [ 10 , 11 ]. The call for differentiated service delivery and the integration of HIV care with other primary health services underscores a global movement towards more efficient, responsive, and sustainable care models [ 12 , 13 ]. China has made significant strides in HIV epidemic control, largely underpinned by its “Four Frees and One Care” policy[ 14 ]. With over 90% of diagnosed PLWH on ART and high rates of viral suppression nationally, the focus is now intensifying on enhancing the quality and long-term sustainability of care, which presents ongoing challenges [ 15 ]. The latest national guidelines explicitly advocate for a comprehensive, life-cycle management approach to HIV, emphasizing the need to address both AIDS-defining and non-AIDS-defining illnesses within a coordinated care framework [ 16 ]. This policy direction creates an imperative to reform traditional ART clinic operations, which were often characterized by overcrowding, transactional patient-provider interactions, and limited capacity for in-depth counseling and co-morbidity management. Yunnan Province holds a unique and critical position in China's HIV response. Its complex profile—as a border region, an area of multi-ethnic composition, and a historically under-resourced part of the country where the first domestic cases were identified—resulted in it bearing the highest burden of HIV infections nationally for many years[ 17 ]. While the rate of new infections has declined, a large and sustained patient population continues to exert significant pressure on the healthcare system[ 18 ]. To address the persistent service delivery gaps exacerbated by these conditions, the province has pioneered the systematic implementation of Standardized HIV Care Clinics as a strategic innovation[ 19 ].This initiative represents a deliberate shift from a disease-centric, public health-driven model to a patient-centred, clinically integrated one. It involves a multifaceted restructuring of the clinical environment, workflow processes, staff roles, and the use of digital health tools, all aimed at creating an efficient, dignified, and sustainable care experience for this longstanding epidemic. While early reports suggest that this standardization drive has improved operational metrics and patient satisfaction [19 ], there remains a critical gap in understanding its implementation process from the viewpoint of those who enact it daily: the frontline healthcare workers. Their experiences, perceptions, and adaptations are the linchpin of any health service reform, determining its feasibility, fidelity, and ultimate impact [ 20 , 21 ]. A systematic, qualitative exploration of the frontline perspective is essential to uncover the tacit knowledge, perceived mechanisms of change, contextual challenges, and unintended consequences that shape the real-world journey from policy to practice. Therefore, this qualitative study aims to address this gap by exploring the implementation of Standardized HIV Care Clinics in Yunnan Province through the lens of frontline health providers. We seek to answer the question: What are the experiences, perceived impacts, and encountered challenges of healthcare workers during the implementation of a standardized, patient-centred HIV care clinic model? By illuminating the lived reality of this transformation, our findings will contribute rich, contextual evidence to the global discourse on optimizing chronic HIV care delivery, offering practical insights for policymakers and clinic managers seeking to navigate similar health system improvements in China and beyond. Methods Study Design We conducted an exploratory qualitative study using focus group discussions (FGDs) to explore healthcare providers' perceptions and experiences regarding the construction and impact of standardized HIV Care Clinics in Yunnan Province, China. An interview guide was developed based on a review of the literature and preliminary consultations with local experts, focusing on: 1) workflow optimization, 2) patient service changes, 3) team collaboration, 4) capacity development, and 5) implementation barriers (Supplementary File 1).The session concluded with a summary and verification of the key points discussed. This study was approved by the Ethics Committee of Yunnan Provincial Infectious Disease Hospital (Ref:Ke2024050). The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided written informed consent. Audio recordings were securely stored and anonymized during transcription. Researcher Characteristics and Reflexivity This study was reported in accordance with the Standards for Reporting Qualitative Research (SRQR) to ensure methodological transparency [ 22 ]. The research team consisted of a principal investigator (a master’s candidate and licensed counselor in psychology) and a research assistant (a senior social worker), both with over a decade of clinical experience in HIV care. All FGDs were moderated by the principal investigator. Given the team’s extensive prior involvement in HIV care, which could influence data collection and interpretation, several strategies were employed to mitigate potential bias and enhance rigor: adherence to a semi-structured discussion guide ensured consistent and neutral facilitation; a reflective journal was maintained throughout the research process to document and scrutinize preconceptions; and ongoing supervision was provided by a senior researcher with over 20 years of experience in HIV treatment management. Study Setting and Participants All interviews were conducted in person between March and June 2025. We employed maximum variation purposive sampling to recruit healthcare providers directly involved in the clinic operations from five representative sites across multiple administrative levels in Yunnan Province. The sites included provincial, prefectural, and county-level hospitals. Recruitment continued until thematic saturation was confirmed at the final site (Yuxi First People’s Hospital). A total of 28 participants were enrolled, comprising physicians (n = 12), and case managers (n = 16). Detailed participant characteristics are provided in Table 1 .Five focus group discussions (FGDs), each lasting 60–120 minutes. Quotations included in this paper were translated from the original Chinese transcripts into English. Table 1 Characteristics of Participants (N = 28) Characteristic n (%) / Mean (SD) Age, years 44.8 (8.78) Gender Female 23 (82.1%) Male 5 (17.9%) Region Dehong 9 (32.1%) Kunming 6 (21.4%) Yuanyang 7 (25.0%) Yuxi 3 (10.7%) Zhaotong 3 (10.7%) Occupation Physician 12 (42.9%) Case Manager 16 (57.1%) Work Experience ≤ 5 years 1 (3.6%) 5–15 years 8 (28.6%) ≥ 15 years 19 (67.9%) Data Analysis We employed the Framework Method for qualitative analysis, as described by Gale (2013), which is well-suited for producing structured, actionable findings while preserving interpretive depth in applied health research[23,24 ]. First, transcription produced verbatim textual records of all interviews. During familiarisation, the research team repeatedly read the transcripts and listened to recordings to immerse themselves in the data. Coding was then conducted inductively, with two researchers independently applying descriptive labels to meaningful segments of text across the datasets.Through iterative discussion within the project team at each stage of analysis, a working analytical framework was developed, systematically applied to all transcripts, and subsequently consolidated. Following these iterations, consensus was reached among all authors, resulting in a final framework consisting of 14 codes within 4 domains. Discrepancies were resolved through consensus discussions with a senior researcher.During the charting stage, coded data were synthesized into a thematic matrix. The subsequent interpretation stage involved analyzing this matrix to explore relationships between categories and construct the analytical narrative presented in the results, supported by concept mapping to visualize key thematic connections[ 24 , 25 ]. Results The framework analysis of interview data revealed four interconnected domains central to the implementation of standardized HIV clinics: (1) Restructuring Workflow and Environment, (2) Deepening Patient-Provider Interaction, (3) Building Organizational Support and Team Capacity, and (4) Navigating Persistent Challenges. The following sections detail each domain, followed by a synthesis of their dynamic relationships.The domains and interconnections described above culminate in an integrative conceptual model (Fig. 1 ). This model reveals the core mechanism underlying the implementation of standardization. On one hand, formal workflow improvements provide healthcare workers with clear guidelines and efficiency tools, which facilitate higher-quality interactions. On the other hand, the trust and on-site collaboration generated through enhanced interactions between providers and patients can, in turn, inform and optimize the details of workflows, making them more responsive to practical needs. Organizational support—such as managerial endorsement and sustained training resources—does not produce outcomes directly, but rather functions by reinforcing this interplay cycle. When this cycle is established and gains momentum, the clinic system acquires a dynamic capacity to navigate internal and external barriers and achieve sustained standardization. The following thematic analysis delves to explore the meanings, contexts, and interrelationships embedded in these discussions. Domain 1: Restructuring Workflow and Environment: From Chaos to Order This domain describes the systemic transformation of clinics from a state of chaos and unpredictability to one characterized by order, predictability, and efficiency, achieved through interrelated structural reorganizations. Standardized Protocols and Role Clarification The establishment of clear, standardized protocols and the clarification of professional roles were the foundational steps. This involved implementing formal appointment,registration and triage systems and transferring non-core tasks (e.g., phlebotomy, medication dispensing) to respective hospital departments. This delineation enabled clinicians to concentrate on clinical diagnosis and treatment, while case managers could focus exclusively on medication adherence counseling and psychosocial support. “The process is much smoother now: register first, then get your vitals checked, followed by case counseling and finally seeing the doctor. The whole flow feels just like a regular outpatient visit. Looking back, HIV care used to be entirely different—so special that we didn't even have a registration system. Everything was done huddled together in one room, almost in secrecy.Medications were handed out without even waiting to review the lab results.” (YY-01) “Before, I had to handle things like drawing blood and giving out medication. Now, my role is really focused on patient counseling. I’ve been able to notice things I might have missed before—like when patients are skipping doses, or when they’re going through really difficult situations at home.” (DH-04) Implementation of a Scheduled Appointment System In parallel, the introduction of a scheduled appointment system fundamentally transformed patient flow management. This shift from walk-in to appointment-based visits eliminated chaotic crowding, reduced unpredictable wait times, and instilled a sense of order and predictability for both patients and staff. “In the past, we didn’t have registration or appointment systems—it wasn’t really a structured medical practice. We were just ‘like a crow waiting by a dying dog,’completely passive. Sometimes it was so crowded we couldn’t even speak to each patient; other times, we waited all morning and only saw one or two people.” (ZT-03) “The appointment system lets us balance the load, especially during peak times like festivals. We can proactively schedule, which cuts down chaotic crowding and makes the day manageable for everyone.” (YX-01, DH-01) Clinic Spatial Reorganization The physical redesign of the clinic space enhanced service quality, patient dignity, and clinical efficiency. Creating separate waiting areas and medical consultation rooms directly addressed privacy concerns and stigma. Reorganization also optimized workspaces: standardized filing systems streamlined record retrieval, while a redesigned, face-to-face seating arrangement replaced the limiting medication dispensing window. This new layout actively supported more comprehensive counseling and shared decision-making. “We used to dispense medicine through a small window, just like a bank teller. Patients stood on one side, we stood on the other—it was tiring for everyone. Now it's completely different. We've turned that crowded corner into a proper clinic with a waiting area and private rooms. Patients can sit down with us face-to-face, take their time, and discuss their health concerns in confidence.” (DH-05) Integrated Information Systems A provincially developed and nationally pioneering information system, designed specifically for HIV ART management, served as a central digital facilitator. This system centralized patient records, visualized longitudinal clinical data, and automatically flagged abnormal values, thereby streamlining clinical decision-making and reducing administrative burdens. It operated with robust security protocols to protect patient privacy. Concurrently, mobile applications granted patients direct access to their laboratory results and appointment schedules, transforming them into informed, active participants in their care. “The system gives me an instant, complete overview of a patient’s history right on the screen. It flags risks so I can think deeper about the clinical picture, instead of digging through piles of paper charts.” (KM-03) “Now, patients check their lab results on the mini-program before their visit. They come in and ask us specific things like, ‘What does this red arrow in my report mean?’ You see, they’re really becoming engaged partners in their care.” (ZT-02) Counseling & Assessment Toolkit As part of the infrastructural upgrade, each clinic was equipped with a standardized counseling and assessment toolkit. This included visual aids such as medication identification charts and counseling guides, as well as basic diagnostic instruments like blood pressure monitors. The provision of these physical resources established a consistent, tangible foundation for all clinical encounters. “Now, every consultation room has the same set of tools—the medication charts, the picture guides, the blood pressure monitor, the height-weight scale, and even the specialized filing cabinets for records. All this equipment is here to stay: the smaller items are standard, provincially issued kits, and the larger installations were supported through corresponding project funds.” (ZT-02) “Now, checking blood pressure has become a routine part of our visit. It’s only after we started measuring it routinely that we realized how many patients actually have high blood pressure! We provide counseling on the spot or refer them directly to the hypertension clinic. This is about taking full responsibility for our patients' overall health.” (DH-07) Critically, the combination of procedural, spatial, and digital restructuring produced a synergistic outcome termed the “efficiency paradox.” While standardized processes and tools allowed for more in-depth, comprehensive consultations with each patient, the clinic’s overall throughput and operational efficiency improved simultaneously. This counter-intuitive result was achieved by eliminating the systemic inefficiencies—such as chaotic crowding, time wasted searching for files, and unpredictable patient flow—that had previously consumed substantial resources. Consequently, depth of care and operational efficiency, once seen as competing priorities, became synergistically reinforcing goals of the standardized clinic model. Domain 2: Deepening Patient-Provider Interaction This domain captures the qualitative shift in consultations from transactional, time-pressured exchanges to patient-centered, relational communication and partnership. Facilitating Understanding Through Structured Interaction Structured interactions, through standardized protocols, visual aids, and enhanced communication skills, served as the fundamental practice for building trust and collaborative relationships. This combined approach ensured that mutual understanding was not merely an exchange of information, but a relational process that made patients feel heard, valued, and engaged as active participants in their care. “Using these picture books and pill charts during counseling makes things click right away. Especially here in our ethnic region, with many who don’t read or are older—just talking might not get through. But when you point at the pictures, it just makes sense visually.” (YY-05) “Before, I would just tell patients to take their medicine. Now, I’ve learned to ask open questions like, ‘What has made it difficult to take your pills in the past three months?’ This simple shift makes patients feel heard, and they’re willing to share the real challenges they face. The biggest change is that they trust me more.” (ZT-03) Fostering Patient Self-Management Patients demonstrated enhanced initiative by consistently adhering to scheduled follow-ups, proactively monitoring their laboratory results via digital tools, and actively seeking clarifications from their physicians and case managers. This transition to a more engaged role contributed to improved medication adherence and, ultimately, better clinical outcomes. “Patients are no longer passive. They monitor their lab results on the app and arrive at appointments with specific, informed questions. They ask, ‘My viral load is undetectable, but there’s still a red arrow (abnormal marker) on the test report. What’s going on?’ They are becoming true partners in managing their health.” (YY-04) Co-constructing a Dignified Clinical Experience The cumulative effect of private spaces, scheduled appointments, and respectful communication—combined with a renewed focus on comprehensive clinical consultation—co-constructed a significantly improved care experience. This integrated approach not only directly mitigated HIV-related stigma but also ensured that co-morbidities were actively identified, addressed through on-site management, or appropriately referred. “You know what they tell me now? They say, ‘Things are in order now.’ They really notice the queuing system and the appointments. But what strikes me most is that they feel the care is more thorough now, and many say, ‘If I don’t feel well, I think of coming here first.’” (ZT-02) Realizing Relational Value and Professional Fulfillment For providers, these deeper interactions led to an expanded professional role—from medication dispensers to holistic care managers—and generated a powerful sense of accomplishment and relational value. “A patient who had struggled for years but finally achieved excellent health brought us a hand-made thank-you plaque. He said, ‘This belongs to your team.’ You know, in that moment, it hit me — I wasn’t just someone prescribing pills anymore. That is the core of why we do this work.” (DH-04) Domain 3: Building Organizational Support and Team Capacity Leadership Endorsement and Resource Allocation Active, tangible support from hospital leadership was universally identified as the indispensable foundation, providing legitimacy, resources, and strategic prioritization. “This initiative succeeded because it was a hospital-level priority, not just a departmental project. Leadership approved the physical renovations, protected our time for training, and even authorized an additional position dedicated to patient counseling.” (YY-04) Experiential and Empowering Training Capacity was built through an experiential training model that moved beyond theory, involving initial workshops followed by immersive visits to pioneering sites, which equipped teams with practical problem-solving skills. “The first classroom session was abstract… The breakthrough came during the field visit in Chuxiong. Seeing a functioning model, talking to their staff, and then re-sketching our own clinic’s future—that’s when everything clicked.” (ZT-02) Flexible Implementation and Reinforcing Feedback The principle of flexible implementation allowed adaptation to local contexts, preventing resistance. Performance-aware feedback and incentive structures were introduced in some sites to reinforce and sustain the new way of working. “Because of limited space, our case manager and doctor share a room. Patients follow the visit flow: they see the case manager first, then the doctor, so their work doesn’t interfere.” (DH-05) “We moved towards a performance-fluctuating system. Compensation now reflects workload complexity and outcomes like patient retention rates. It’s a fairer system that visibly rewards the extra effort required for deep counseling and careful management, reinforcing the new way of working.” (KM-01) Domain 4: Navigating Persistent Challenges Resource Constraints and Systemic Silos Chronic human resource scarcity and persistent “last-mile” integration gaps with key hospital departments (e.g., central pharmacy) remained critical bottlenecks, constraining the model’s full potential. “The new model requires more intensive patient engagement, but our absolute number of doctors and nurses hasn’t changed. We are asked to provide higher-quality care per patient while being stretched as thin as before. It creates a constant pressure point that threatens burnout and sustainability.” (CH-02) “We still handle a lot of medication dispensing ourselves because the pharmacy’s system isn’t aligned with our outpatient flow. It’s a major inefficiency we haven’t fully solved.” (DH-06) Differential Adaptation among Patients and Staff Adaptation to the new system was not universal. A portion of patients, particularly older or from rural areas, struggled with new norms like appointments, while some staff exhibited resistance to changing long-held practices. “About 30% of patients don’t understand and value the appointment system. Especially older patients or those from very rural areas, still come whenever they want. It disrupts the flow and challenges the principle of the standard for everyone.” (YY-01) “A portion of the team still thinks, ‘The old way was fine, why change?’ They struggle to see that managing HIV as a chronic disease for a growing population requires this new level of organization and professionalism.” (KM-01) The Emotional Labor Burden A profound and persistent challenge was the enduring emotional and psychological toll of HIV care. While systemic efficiencies reduced administrative stress, the “heart-fatigue” from managing patient stigma, anxiety, and grief remained largely unaddressed by the support ecosystem. “The chaos is gone, so we’re less exhausted from that. But the ‘heart-fatigue’ is still there—carrying the patients’ stories of stigma, managing their anxieties about aging with HIV, and confronting grief. This work sits in your heart. We have no formal, structured psychological supervision to process this.” (DH-02) Discussion This qualitative study draws on FGD to examine healthcare providers’ perspectives regarding the implementation and impact of Standardized HIV Care Clinic in Yunnan Province, China. Our findings reveal that this initiative represents more than a simple procedural update; it is a systemic transformation that restructured workflows, deepened human interactions, and was fundamentally enabled by organizational support, all while navigating persistent challenges. The resulting conceptual model illustrated how structural and humanistic changes synergistically drive improvements in care quality and professional efficacy. This discussion interprets these findings within the broader context of health systems strengthening and chronic care management. Consistent with models of healthcare quality improvement that emphasize both structural and process factors [ 26 , 27 ], our study identified workflow standardization as a core step. The implementation of clear protocols, appointment systems, and spatial redesign directly addressed the chaos of the prior model, creating a predictable environment necessary for higher-order care activities. This aligns with established principles of health service design where optimizing the “system” is a prerequisite for reliable, safe, and dignified care [ 28 , 29 ]. Beyond structure, a central finding was the critical role of human empowerment and interaction. The training in communication skills like Motivational Interviewing and the use of visual aids reflect an investment in the “soft technology” of care, which is increasingly recognized as vital for managing chronic conditions [ 30 , 31 ]. The concurrent transition of patients from passive recipients to active partners and the accompanying surge in provider efficacy underscore a dual imperative: durable chronic-disease management is predicated on the simultaneous empowerment of patients and clinicians[ 32 ]. Crucially, this transformation was not automatic. It was fueled by multifaceted organizational support, including leadership commitment, experiential training, and sanctioned flexibility. This highlights that successful health service innovation depends heavily on creating an enabling institutional environment that provides both resources and psychological safety for change [ 33 ]. The persistence of challenges like resource constraints and emotional burden further confirms that technical interventions alone are insufficient without addressing deeper systemic and workforce well-being issues [ 34 , 35 ]. Our conceptual model contributes to the literature by proposing a dynamic structuration model for clinic-level health system improvement. It moves beyond listing facilitators and barriers to depict their dynamic interaction.The Synergy: The model posits that “System Redesign” and “Human Empowerment” are not sequential but concurrent and mutually reinforcing. For instance, a streamlined appointment system (a structural change) creates the time necessary for a motivational interview (a humanistic skill), while effective communication (a humanistic skill) ensures patient buy-in for the new system (structural change). This synergy resolves the “efficiency paradox”, demonstrating that investing in deeper care can co-exist with improved throughput when systemic waste is eliminated—a finding supported by operations management research in healthcare[ 36 ] .The Essential Enabler: The model positions “Organizational Support” not as a background factor but as the essential fuel for both engines. This aligns with implementation science frameworks, such as the Consolidated Framework for Implementation Research, which emphasize the inner organizational setting as a critical determinant of implementation success [ 37 , 38 ].The Ongoing Context: By framing “challenges and barriers” as a continuous backdrop, the model realistically acknowledges that improvement is a journey, not a destination. It suggests that future gains may require different types of interventions, particularly those addressing workforce psychosocial support and inter-sectoral collaboration[ 39 ]. The study calls for an integrated approach to investment: funding and policies must simultaneously shore up the “hardware” of care—physical clinics, IT infrastructure—and its “software,” namely communication training and psychosocial support for staff. Standardized protocols should be mandated in tandem with ongoing, experiential training and team-building that enable staff to bring those protocols to life [ 40 ].Building on the adaptive-intervention framework, flexible adaptation is best understood not as simple delegation, but as a principled sequence of decision rules. Successful implementation requires balancing fidelity to core model components with autonomy for local problem-solving. Leaders must actively champion the change, provide tangible resources, and create feedback mechanisms (like adjusted performance incentives) to sustain motivation [ 41 ]. The unresolved challenges point to clear priorities. Future initiatives must explicitly plan for: a) Workforce protection, including measures to address the specific emotional labor of HIV care to prevent burnout[ 39 ]; and b) Enhanced patient navigation, providing tailored support (e.g., through peer workers) to help vulnerable patients adapt to new systems, ensuring equity within standardization [ 42 ].The primary goal is to establish an integrated service delivery model within the standardized clinic. This model moves beyond exclusive HIV care to address the comprehensive health needs of people living with HIV, thereby enhancing care quality, optimizing resources, and reducing stigma through service integration[8,43]. This study has limitations. Its focus on provider perspectives, while a strength in depth, means the patient voice is secondhand represented. The sample, though diverse across Yunnan, may not capture all regional variations in China. Furthermore, the cross-sectional design describes mechanisms and outcomes based on recall and perception; longitudinal research is needed to assess sustainability and quantifiable health outcomes. The study’s strengths lie in its rich qualitative data, rigorous analytical process with intercoder reliability checks, and the development of an integrative conceptual model derived directly from frontline experiences. By capturing the nuances of implementation from the perspective of those enacting the change, it provides practical insights often missed in purely outcome-focused evaluations. Conclusion The standard HIV care clinics in Yunnan is a significant step toward sustainable, high-quality chronic HIV care. Our analysis demonstrates that its effectiveness stems from a dual focus on rationalizing care systems and empowering the people within them—patients and providers alike. This transformation is sustainably powered by intentional organizational support. The persistent challenges, particularly around staff well-being and resource equity, chart the course for the next phase of health system strengthening. The proposed a dynamic structuration model offers a valuable framework for designing and evaluating similar chronic care service improvements in other contexts. Declarations Authors ’ contributions Conception and study design by YZ, TL and LL. Data collection, including the conduct of interviews, and qualitative data analysis were performed by YZ, YZh, JCL, and LL. The manuscript was drafted by YZ and subsequently revised and critically reviewed by XD, TL and YL. All authors read and approved the final version of the manuscript. Funding This work was supported by Yunnan Clinical Research Center for Infectious Disease (AIDS)( 202405AJ310002) Availability of data and materials The full interview transcripts cannot be shared publicly to protect participant privacy. The semi-structured interview guide is available as supplementary files with this publication. Qualitative codebook will be available upon request on a case-by-case basis. Ethics approval and consent to participate This study was approved by the Ethics Committee of Yunnan Provincial Infectious Disease Hospital (Ref:Ke2024050) . All participants provided written informed consent. Audio recordings were securely stored and anonymized during transcription. Consent for publication Not applicable. Competing interests The authors have no conflicts of interest to declare. Author details Yunnan Provincial Hospital of Infectious Disease/Yunnan AIDS Care Center, Kunming, China Clinical trial number Not applicable. References Mu W, Patankar V, Kitchen S, Zhen A. Examining Chronic Inflammation, Immune Metabolism, and T Cell Dysfunction in HIV Infection. Viruses. 2024;16(2):219. 10.3390/v16020219 . Mbalinda SN, Lusota DA, Muddu M, Nyashanu M. 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McCreesh-Toselli S, Torline J, Gouse H, Robbins RN, Mellins CA, Remien RH, Rowe J, Peton N, Rabie S, Joska JA. Staff Perceptions of Preimplementation Barriers and Facilitators to a Mobile Health Antiretroviral Therapy Adherence Counseling Intervention in South Africa: Qualitative Study. JMIR Mhealth Uhealth., Mak J, Bafagih S, Arcand J. Implementation science in nutrition practice: A review of the Consolidated Framework for Implementation Research. Nutr Clin Pract. 2025;40(6):1323–1347. 10.1002/ncp.70020 O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51. 10.1097/ACM.0000000000000388 . Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. 10.1186/1471-2288-13-117 . Zhang H, Xiao L, Ren G. Experiences of Social Support Among Chinese Women with Breast Cancer: A Qualitative Analysis Using a Framework Approach. Med Sci Monit. 2018;24:574–81. 10.12659/msm.908458 . Anderson M, Gluckman G, Ajith T, Kirk E, Memtsa M. Service evaluation of an early pregnancy loss support clinic in an inner London early pregnancy unit. BMC Health Serv Res. 2024;24(1):1328. 10.1186/s12913-024-11750-1 . Tossaint-Schoenmakers R, Kasteleyn MJ, Rauwerdink A, Chavannes N, Willems S, Talboom-Kamp EPWA. Development of a Quality Management Model and Self-assessment Questionnaire for Hybrid Health Care: Concept Mapping Study. JMIR Form Res. 2022;6(7):e38683. 10.2196/38683 . Li C, Cui L, Zhou S, He A, Ni Z. The formation mechanism of primary health care team effectiveness: a qualitative comparative analysis research. BMC Prim Care. 2024;25(1):45. 10.1186/s12875-024-02278-8 . Okunade OS, Oladokun VO, Iwu-Jaja CJ, Jaca A, Wiysonge CS. Protocol for a scoping review of work system design in health care. 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Kumar M, Osborn TL, Mugo C, Akbarialiabad H, Warfa O, Mbuthia WM, Wambugu C, Ngunu C, Gohar F, Mwaniga S, Njuguna S, Saxena S. A Four-Component Framework Toward Patient-Centered, Integrated Mental Healthcare in Kenya. Front Public Health. 2021;9:756861. 10.3389/fpubh.2021.756861 . Niekerk LV, Manderson L, Fosiko N, Likaka A, Blauvelt CP, Msiska B, Rifkin S. Identifying Positive Practices to Institutionalize Social Innovation in the Malawian Health System. Int J Health Policy Manag. 2024;13:8141. 10.34172/ijhpm.8141 . Forsgren L, Tediosi F, Blanchet K, Saulnier DD. Health systems resilience in practice: a scoping review to identify strategies for building resilience. BMC Health Serv Res. 2022;22(1):1173. 10.1186/s12913-022-08544-8 . Guraya SY, Dias JM, Eladl MA, Rustom AMR, Alalawi FAS, Alhammadi MHS, Ahmed YAM, Al Shamsi AAOT, Bilalaga SJ, Nicholson A, Malik H, Salman Guraya S. Unfolding insights about resilience and its coping strategies by medical academics and healthcare professionals at their workplaces: a thematic qualitative analysis. BMC Med Educ. 2025;25(1):177. 10.1186/s12909-024-06415-w . Aquino ACT, Gonçalves MFS, Mol MPG. Healthcare waste and circular economy principles: It is time to improve! Waste Manag Res. 2024;42(10):857–9. 10.1177/0734242X241270979 . Birken SA, Wagi CR, Peluso AG, Kegler MC, Baloh J, Adsul P, Fernandez ME, Masud M, Huang TT, Lee M, Wangen M, Nilsen P, Bender M, Choy-Brown M, Ryan G, Randazzo A, Ko LK. Toward a more comprehensive understanding of organizational influences on implementation: the organization theory for implementation science framework. Front Health Serv. 2023;3:1142598. 10.3389/frhs.2023.1142598 . Lyng HB, Ree E, Strømme T, Johannessen T, Aase I, Ullebust B, Thomsen LH, Holen-Rabbersvik E, Schibevaag L, Bates DW, Wiig S. Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study. BMC Health Serv Res. 2024;24(1):528. 10.1186/s12913-024-10985-2 . McNamara M, Ward M, Teeling SP. Making a Sustainable Difference to People, Processes and Systems: Whole-Systems Approaches to Process Improvement in Health Systems. Int J Environ Res Public Health. 2023;20(7):5232. 10.3390/ijerph20075232 . Benjamin GC. The Future of Public Health: Ensuring An Adequate Infrastructure. Milbank Q. 2023;101(S1):637–52. 10.1111/1468-0009.12637 . Seewald NJ. Adaptive Interventions for a Dynamic and Responsive Public Health Approach. Am J Public Health. 2023;113(1):37–9. 10.2105/AJPH.2022.307157 . Villacis-Alvarez E, Haworth-Brockman M, Maier K, Sobie C, Pashe H, Baliddawa J, Daniels N, Murdock R, Russell R, Dan C, Woodhouse F, Cusson S, Patrick L, Schenkels M, Payne M, Kasper K, MacKenzie LJ, Ireland L, Templeton K, Keynan Y, Rueda ZV. Our needs, our priorities, listen to us! recommendations for improving HIV prevention and the cascade of care from people living with HIV in Manitoba, Canada: a qualitative study. BMC Health Serv Res. 2025;25(1):587. 10.1186/s12913-025-12645-5 . Musuka G, Moyo E, Cuadros D, Herrera H, Dzinamarira T, Redefining. HIV care: a path toward sustainability post-UNAIDS 95-95-95 targets. Front Public Health. 2023;11:1273720. 10.3389/fpubh.2023.1273720 . Additional Declarations No competing interests reported. Supplementary Files FocusGroupDiscussionGuide.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 02 Mar, 2026 Reviews received at journal 24 Feb, 2026 Reviewers agreed at journal 24 Feb, 2026 Reviewers invited by journal 24 Feb, 2026 Editor invited by journal 30 Jan, 2026 Editor assigned by journal 19 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 12 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuehua","middleName":"","lastName":"Zhang","suffix":""},{"id":596458945,"identity":"839c0c3b-93a7-43ad-b0e5-8cb988e84c5a","order_by":2,"name":"Jincheng Lou","email":"","orcid":"","institution":"Yunnan Provincial Infectious Disease Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jincheng","middleName":"","lastName":"Lou","suffix":""},{"id":596458946,"identity":"1cd612f4-db12-4bb6-ba15-e7a397ab8856","order_by":3,"name":"Tianshu Li","email":"","orcid":"","institution":"Yunnan Provincial Infectious Disease Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tianshu","middleName":"","lastName":"Li","suffix":""},{"id":596458947,"identity":"fe28f924-82be-4c33-a1e2-34ad7594ebea","order_by":4,"name":"Xingqi Dong","email":"","orcid":"","institution":"Yunnan Provincial Infectious Disease 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Provincial Infectious Disease Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yunfei","middleName":"","lastName":"Lao","suffix":""}],"badges":[],"createdAt":"2026-01-13 03:08:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8586604/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8586604/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103589933,"identity":"1437687a-8ade-452d-9d95-3e27474004ea","added_by":"auto","created_at":"2026-02-27 12:00:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":187650,"visible":true,"origin":"","legend":"\u003cp\u003ePathways to Standardized HIV Clinic Implementation: A Dynamic Structuration Model of Workflow and Interaction\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8586604/v1/0750870a6e7278c5ba12f301.png"},{"id":104399131,"identity":"8272194b-5d48-44f1-b146-4b7a47da4302","added_by":"auto","created_at":"2026-03-11 12:04:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1170885,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8586604/v1/047a7843-3a07-4f91-97d7-ae9a45c81255.pdf"},{"id":103589934,"identity":"6c870156-5628-4544-9450-68281b41110a","added_by":"auto","created_at":"2026-02-27 12:00:02","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14723,"visible":true,"origin":"","legend":"","description":"","filename":"FocusGroupDiscussionGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-8586604/v1/acd5ad063b661c2dce444333.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementing Standardized HIV Care Clinics: A Qualitative Study from Healthcare Providers in Yunnan, China","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe global scale-up of antiretroviral therapy (ART) has transformed HIV infection from a fatal disease into a manageable chronic condition [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This remarkable achievement has shifted the clinical paradigm and, consequently, the demands placed on healthcare systems. As life expectancy for people living with HIV (PLWH) approaches that of the general population, their health needs have evolved beyond virological suppression to encompass the holistic management of ageing-related comorbidities, mental health, and long-term quality of life [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This shift necessitates a corresponding transformation in service delivery models, from a narrow focus on medication dispensing to a broader, patient-centred approach that integrates chronic disease management, psychosocial support, and health promotion [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn response, health systems worldwide are re-evaluating and redesigning their HIV care services. The \u0026ldquo;treat-all\u0026rdquo; policy and the pursuit of the UNAIDS 95-95-95 targets have placed unprecedented volumes of patients into long-term care, straining existing clinic infrastructures [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Traditional, often fragmented and episodic, ART delivery models are increasingly recognized as inadequate for sustaining lifelong engagement and addressing the complex, multifaceted needs of a stable, ageing patient population [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The call for differentiated service delivery and the integration of HIV care with other primary health services underscores a global movement towards more efficient, responsive, and sustainable care models [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChina has made significant strides in HIV epidemic control, largely underpinned by its \u0026ldquo;Four Frees and One Care\u0026rdquo; policy[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. With over 90% of diagnosed PLWH on ART and high rates of viral suppression nationally, the focus is now intensifying on enhancing the quality and long-term sustainability of care, which presents ongoing challenges [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The latest national guidelines explicitly advocate for a comprehensive, life-cycle management approach to HIV, emphasizing the need to address both AIDS-defining and non-AIDS-defining illnesses within a coordinated care framework [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This policy direction creates an imperative to reform traditional ART clinic operations, which were often characterized by overcrowding, transactional patient-provider interactions, and limited capacity for in-depth counseling and co-morbidity management.\u003c/p\u003e \u003cp\u003eYunnan Province holds a unique and critical position in China's HIV response. Its complex profile\u0026mdash;as a border region, an area of multi-ethnic composition, and a historically under-resourced part of the country where the first domestic cases were identified\u0026mdash;resulted in it bearing the highest burden of HIV infections nationally for many years[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. While the rate of new infections has declined, a large and sustained patient population continues to exert significant pressure on the healthcare system[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. To address the persistent service delivery gaps exacerbated by these conditions, the province has pioneered the systematic implementation of Standardized HIV Care Clinics as a strategic innovation[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].This initiative represents a deliberate shift from a disease-centric, public health-driven model to a patient-centred, clinically integrated one. It involves a multifaceted restructuring of the clinical environment, workflow processes, staff roles, and the use of digital health tools, all aimed at creating an efficient, dignified, and sustainable care experience for this longstanding epidemic.\u003c/p\u003e \u003cp\u003eWhile early reports suggest that this standardization drive has improved operational metrics and patient satisfaction [19 ], there remains a critical gap in understanding its implementation process from the viewpoint of those who enact it daily: the frontline healthcare workers. Their experiences, perceptions, and adaptations are the linchpin of any health service reform, determining its feasibility, fidelity, and ultimate impact [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A systematic, qualitative exploration of the frontline perspective is essential to uncover the tacit knowledge, perceived mechanisms of change, contextual challenges, and unintended consequences that shape the real-world journey from policy to practice.\u003c/p\u003e \u003cp\u003eTherefore, this qualitative study aims to address this gap by exploring the implementation of Standardized HIV Care Clinics in Yunnan Province through the lens of frontline health providers. We seek to answer the question: What are the experiences, perceived impacts, and encountered challenges of healthcare workers during the implementation of a standardized, patient-centred HIV care clinic model? By illuminating the lived reality of this transformation, our findings will contribute rich, contextual evidence to the global discourse on optimizing chronic HIV care delivery, offering practical insights for policymakers and clinic managers seeking to navigate similar health system improvements in China and beyond.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003e We conducted an exploratory qualitative study using focus group discussions (FGDs) to explore healthcare providers' perceptions and experiences regarding the construction and impact of standardized HIV Care Clinics in Yunnan Province, China. An interview guide was developed based on a review of the literature and preliminary consultations with local experts, focusing on: 1) workflow optimization, 2) patient service changes, 3) team collaboration, 4) capacity development, and 5) implementation barriers (Supplementary File 1).The session concluded with a summary and verification of the key points discussed. This study was approved by the Ethics Committee of Yunnan Provincial Infectious Disease Hospital (Ref:Ke2024050). The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided written informed consent. Audio recordings were securely stored and anonymized during transcription.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResearcher Characteristics and Reflexivity\u003c/h3\u003e\n\u003cp\u003eThis study was reported in accordance with the Standards for Reporting Qualitative Research (SRQR) to ensure methodological transparency [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The research team consisted of a principal investigator (a master\u0026rsquo;s candidate and licensed counselor in psychology) and a research assistant (a senior social worker), both with over a decade of clinical experience in HIV care. All FGDs were moderated by the principal investigator. Given the team\u0026rsquo;s extensive prior involvement in HIV care, which could influence data collection and interpretation, several strategies were employed to mitigate potential bias and enhance rigor: adherence to a semi-structured discussion guide ensured consistent and neutral facilitation; a reflective journal was maintained throughout the research process to document and scrutinize preconceptions; and ongoing supervision was provided by a senior researcher with over 20 years of experience in HIV treatment management.\u003c/p\u003e\n\u003ch3\u003eStudy Setting and Participants\u003c/h3\u003e\n\u003cp\u003eAll interviews were conducted in person between March and June 2025. We employed maximum variation purposive sampling to recruit healthcare providers directly involved in the clinic operations from five representative sites across multiple administrative levels in Yunnan Province. The sites included provincial, prefectural, and county-level hospitals. Recruitment continued until thematic saturation was confirmed at the final site (Yuxi First People\u0026rsquo;s Hospital). A total of 28 participants were enrolled, comprising physicians (n\u0026thinsp;=\u0026thinsp;12), and case managers (n\u0026thinsp;=\u0026thinsp;16). Detailed participant characteristics are provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.Five focus group discussions (FGDs), each lasting 60\u0026ndash;120 minutes. Quotations included in this paper were translated from the original Chinese transcripts into English.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of Participants (N\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) / Mean (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44.8 (8.78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (82.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (17.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRegion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDehong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (32.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKunming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (21.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYuanyang\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYuxi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (10.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZhaotong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (10.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (42.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase Manager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork Experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;15 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;15 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (67.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eWe employed the Framework Method for qualitative analysis, as described by Gale (2013), which is well-suited for producing structured, actionable findings while preserving interpretive depth in applied health research[23,24 ].\u003c/p\u003e \u003cp\u003eFirst, transcription produced verbatim textual records of all interviews. During familiarisation, the research team repeatedly read the transcripts and listened to recordings to immerse themselves in the data. Coding was then conducted inductively, with two researchers independently applying descriptive labels to meaningful segments of text across the datasets.Through iterative discussion within the project team at each stage of analysis, a working analytical framework was developed, systematically applied to all transcripts, and subsequently consolidated. Following these iterations, consensus was reached among all authors, resulting in a final framework consisting of 14 codes within 4 domains. Discrepancies were resolved through consensus discussions with a senior researcher.During the charting stage, coded data were synthesized into a thematic matrix. The subsequent interpretation stage involved analyzing this matrix to explore relationships between categories and construct the analytical narrative presented in the results, supported by concept mapping to visualize key thematic connections[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe framework analysis of interview data revealed four interconnected domains central to the implementation of standardized HIV clinics: (1) Restructuring Workflow and Environment, (2) Deepening Patient-Provider Interaction, (3) Building Organizational Support and Team Capacity, and (4) Navigating Persistent Challenges. The following sections detail each domain, followed by a synthesis of their dynamic relationships.The domains and interconnections described above culminate in an integrative conceptual model (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This model reveals the core mechanism underlying the implementation of standardization. On one hand, formal workflow improvements provide healthcare workers with clear guidelines and efficiency tools, which facilitate higher-quality interactions. On the other hand, the trust and on-site collaboration generated through enhanced interactions between providers and patients can, in turn, inform and optimize the details of workflows, making them more responsive to practical needs. Organizational support\u0026mdash;such as managerial endorsement and sustained training resources\u0026mdash;does not produce outcomes directly, but rather functions by reinforcing this interplay cycle. When this cycle is established and gains momentum, the clinic system acquires a dynamic capacity to navigate internal and external barriers and achieve sustained standardization. The following thematic analysis delves to explore the meanings, contexts, and interrelationships embedded in these discussions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDomain 1: Restructuring Workflow and Environment: From Chaos to Order\u003c/h2\u003e \u003cp\u003eThis domain describes the systemic transformation of clinics from a state of chaos and unpredictability to one characterized by order, predictability, and efficiency, achieved through interrelated structural reorganizations.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStandardized Protocols and Role Clarification\u003c/h3\u003e\n\u003cp\u003eThe establishment of clear, standardized protocols and the clarification of professional roles were the foundational steps. This involved implementing formal appointment,registration and triage systems and transferring non-core tasks (e.g., phlebotomy, medication dispensing) to respective hospital departments. This delineation enabled clinicians to concentrate on clinical diagnosis and treatment, while case managers could focus exclusively on medication adherence counseling and psychosocial support.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The process is much smoother now: register first, then get your vitals checked, followed by case counseling and finally seeing the doctor. The whole flow feels just like a regular outpatient visit. Looking back, HIV care used to be entirely different\u0026mdash;so special that we didn't even have a registration system. Everything was done huddled together in one room, almost in secrecy.Medications were handed out without even waiting to review the lab results.\u0026rdquo;\u003c/em\u003e (YY-01)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Before, I had to handle things like drawing blood and giving out medication. Now, my role is really focused on patient counseling. I\u0026rsquo;ve been able to notice things I might have missed before\u0026mdash;like when patients are skipping doses, or when they\u0026rsquo;re going through really difficult situations at home.\u0026rdquo;\u003c/em\u003e (DH-04)\u003c/p\u003e\n\u003ch3\u003eImplementation of a Scheduled Appointment System\u003c/h3\u003e\n\u003cp\u003eIn parallel, the introduction of a scheduled appointment system fundamentally transformed patient flow management. This shift from walk-in to appointment-based visits eliminated chaotic crowding, reduced unpredictable wait times, and instilled a sense of order and predictability for both patients and staff.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In the past, we didn\u0026rsquo;t have registration or appointment systems\u0026mdash;it wasn\u0026rsquo;t really a structured medical practice. We were just \u0026lsquo;like a crow waiting by a dying dog,\u0026rsquo;completely passive. Sometimes it was so crowded we couldn\u0026rsquo;t even speak to each patient; other times, we waited all morning and only saw one or two people.\u0026rdquo;\u003c/em\u003e (ZT-03)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The appointment system lets us balance the load, especially during peak times like festivals. We can proactively schedule, which cuts down chaotic crowding and makes the day manageable for everyone.\u0026rdquo;\u003c/em\u003e (YX-01, DH-01)\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eClinic Spatial Reorganization\u003c/h2\u003e \u003cp\u003eThe physical redesign of the clinic space enhanced service quality, patient dignity, and clinical efficiency. Creating separate waiting areas and medical consultation rooms directly addressed privacy concerns and stigma. Reorganization also optimized workspaces: standardized filing systems streamlined record retrieval, while a redesigned, face-to-face seating arrangement replaced the limiting medication dispensing window. This new layout actively supported more comprehensive counseling and shared decision-making.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We used to dispense medicine through a small window, just like a bank teller. Patients stood on one side, we stood on the other\u0026mdash;it was tiring for everyone. Now it's completely different. We've turned that crowded corner into a proper clinic with a waiting area and private rooms. Patients can sit down with us face-to-face, take their time, and discuss their health concerns in confidence.\u0026rdquo; (DH-05)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIntegrated Information Systems\u003c/h2\u003e \u003cp\u003eA provincially developed and nationally pioneering information system, designed specifically for HIV ART management, served as a central digital facilitator. This system centralized patient records, visualized longitudinal clinical data, and automatically flagged abnormal values, thereby streamlining clinical decision-making and reducing administrative burdens. It operated with robust security protocols to protect patient privacy. Concurrently, mobile applications granted patients direct access to their laboratory results and appointment schedules, transforming them into informed, active participants in their care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The system gives me an instant, complete overview of a patient\u0026rsquo;s history right on the screen. It flags risks so I can think deeper about the clinical picture, instead of digging through piles of paper charts.\u0026rdquo;\u003c/em\u003e (KM-03)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Now, patients check their lab results on the mini-program before their visit. They come in and ask us specific things like, \u0026lsquo;What does this red arrow in my report mean?\u0026rsquo; You see, they\u0026rsquo;re really becoming engaged partners in their care.\u0026rdquo;\u003c/em\u003e(ZT-02)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCounseling \u0026amp; Assessment Toolkit\u003c/h2\u003e \u003cp\u003eAs part of the infrastructural upgrade, each clinic was equipped with a standardized counseling and assessment toolkit. This included visual aids such as medication identification charts and counseling guides, as well as basic diagnostic instruments like blood pressure monitors. The provision of these physical resources established a consistent, tangible foundation for all clinical encounters.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Now, every consultation room has the same set of tools\u0026mdash;the medication charts, the picture guides, the blood pressure monitor, the height-weight scale, and even the specialized filing cabinets for records. All this equipment is here to stay: the smaller items are standard, provincially issued kits, and the larger installations were supported through corresponding project funds.\u0026rdquo;\u003c/em\u003e (ZT-02)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Now, checking blood pressure has become a routine part of our visit. It\u0026rsquo;s only after we started measuring it routinely that we realized how many patients actually have high blood pressure! We provide counseling on the spot or refer them directly to the hypertension clinic. This is about taking full responsibility for our patients' overall health.\u0026rdquo;\u003c/em\u003e (DH-07)\u003c/p\u003e \u003cp\u003eCritically, the combination of procedural, spatial, and digital restructuring produced a synergistic outcome termed the \u0026ldquo;efficiency paradox.\u0026rdquo; While standardized processes and tools allowed for more in-depth, comprehensive consultations with each patient, the clinic\u0026rsquo;s overall throughput and operational efficiency improved simultaneously. This counter-intuitive result was achieved by eliminating the systemic inefficiencies\u0026mdash;such as chaotic crowding, time wasted searching for files, and unpredictable patient flow\u0026mdash;that had previously consumed substantial resources. Consequently, depth of care and operational efficiency, once seen as competing priorities, became synergistically reinforcing goals of the standardized clinic model.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDomain 2: Deepening Patient-Provider Interaction\u003c/h2\u003e \u003cp\u003eThis domain captures the qualitative shift in consultations from transactional, time-pressured exchanges to patient-centered, relational communication and partnership.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFacilitating Understanding Through Structured Interaction\u003c/h2\u003e \u003cp\u003eStructured interactions, through standardized protocols, visual aids, and enhanced communication skills, served as the fundamental practice for building trust and collaborative relationships. This combined approach ensured that mutual understanding was not merely an exchange of information, but a relational process that made patients feel heard, valued, and engaged as active participants in their care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Using these picture books and pill charts during counseling makes things click right away. Especially here in our ethnic region, with many who don\u0026rsquo;t read or are older\u0026mdash;just talking might not get through. But when you point at the pictures, it just makes sense visually.\u0026rdquo;\u003c/em\u003e (YY-05)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Before, I would just tell patients to take their medicine. Now, I\u0026rsquo;ve learned to ask open questions like, \u0026lsquo;What has made it difficult to take your pills in the past three months?\u0026rsquo; This simple shift makes patients feel heard, and they\u0026rsquo;re willing to share the real challenges they face. The biggest change is that they trust me more.\u0026rdquo;\u003c/em\u003e (ZT-03)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFostering Patient Self-Management\u003c/h2\u003e \u003cp\u003ePatients demonstrated enhanced initiative by consistently adhering to scheduled follow-ups, proactively monitoring their laboratory results via digital tools, and actively seeking clarifications from their physicians and case managers. This transition to a more engaged role contributed to improved medication adherence and, ultimately, better clinical outcomes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Patients are no longer passive. They monitor their lab results on the app and arrive at appointments with specific, informed questions. They ask, \u0026lsquo;My viral load is undetectable, but there\u0026rsquo;s still a red arrow (abnormal marker) on the test report. What\u0026rsquo;s going on?\u0026rsquo; They are becoming true partners in managing their health.\u0026rdquo;\u003c/em\u003e (YY-04)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCo-constructing a Dignified Clinical Experience\u003c/h2\u003e \u003cp\u003eThe cumulative effect of private spaces, scheduled appointments, and respectful communication\u0026mdash;combined with a renewed focus on comprehensive clinical consultation\u0026mdash;co-constructed a significantly improved care experience. This integrated approach not only directly mitigated HIV-related stigma but also ensured that co-morbidities were actively identified, addressed through on-site management, or appropriately referred.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You know what they tell me now? They say, \u0026lsquo;Things are in order now.\u0026rsquo; They really notice the queuing system and the appointments. But what strikes me most is that they feel the care is more thorough now, and many say, \u0026lsquo;If I don\u0026rsquo;t feel well, I think of coming here first.\u0026rsquo;\u0026rdquo;\u003c/em\u003e (ZT-02)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRealizing Relational Value and Professional Fulfillment\u003c/h2\u003e \u003cp\u003eFor providers, these deeper interactions led to an expanded professional role\u0026mdash;from medication dispensers to holistic care managers\u0026mdash;and generated a powerful sense of accomplishment and relational value.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;A patient who had struggled for years but finally achieved excellent health brought us a hand-made thank-you plaque. He said, \u0026lsquo;This belongs to your team.\u0026rsquo; You know, in that moment, it hit me \u0026mdash; I wasn\u0026rsquo;t just someone prescribing pills anymore. That is the core of why we do this work.\u0026rdquo;\u003c/em\u003e (DH-04)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eDomain 3: Building Organizational Support and Team Capacity\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eLeadership Endorsement and Resource Allocation\u003c/h2\u003e \u003cp\u003eActive, tangible support from hospital leadership was universally identified as the indispensable foundation, providing legitimacy, resources, and strategic prioritization.\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;This initiative succeeded because it was a hospital-level priority, not just a departmental project. Leadership approved the physical renovations, protected our time for training, and even authorized an additional position dedicated to patient counseling.\u0026rdquo;\u003c/em\u003e (YY-04)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eExperiential and Empowering Training\u003c/h2\u003e \u003cp\u003eCapacity was built through an experiential training model that moved beyond theory, involving initial workshops followed by immersive visits to pioneering sites, which equipped teams with practical problem-solving skills.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The first classroom session was abstract\u0026hellip; The breakthrough came during the field visit in Chuxiong. Seeing a functioning model, talking to their staff, and then re-sketching our own clinic\u0026rsquo;s future\u0026mdash;that\u0026rsquo;s when everything clicked.\u0026rdquo;\u003c/em\u003e (ZT-02)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eFlexible Implementation and Reinforcing Feedback\u003c/h2\u003e \u003cp\u003eThe principle of flexible implementation allowed adaptation to local contexts, preventing resistance. Performance-aware feedback and incentive structures were introduced in some sites to reinforce and sustain the new way of working.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Because of limited space, our case manager and doctor share a room. Patients follow the visit flow: they see the case manager first, then the doctor, so their work doesn\u0026rsquo;t interfere.\u0026rdquo;\u003c/em\u003e (DH-05)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We moved towards a performance-fluctuating system. Compensation now reflects workload complexity and outcomes like patient retention rates. It\u0026rsquo;s a fairer system that visibly rewards the extra effort required for deep counseling and careful management, reinforcing the new way of working.\u0026rdquo;\u003c/em\u003e (KM-01)\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eDomain 4: Navigating Persistent Challenges\u003c/h2\u003e \u003cdiv id=\"Sec24\" class=\"Section4\"\u003e \u003ch2\u003eResource Constraints and Systemic Silos\u003c/h2\u003e \u003cp\u003eChronic human resource scarcity and persistent \u0026ldquo;last-mile\u0026rdquo; integration gaps with key hospital departments (e.g., central pharmacy) remained critical bottlenecks, constraining the model\u0026rsquo;s full potential.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The new model requires more intensive patient engagement, but our absolute number of doctors and nurses hasn\u0026rsquo;t changed. We are asked to provide higher-quality care per patient while being stretched as thin as before. It creates a constant pressure point that threatens burnout and sustainability.\u0026rdquo;\u003c/em\u003e (CH-02)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We still handle a lot of medication dispensing ourselves because the pharmacy\u0026rsquo;s system isn\u0026rsquo;t aligned with our outpatient flow. It\u0026rsquo;s a major inefficiency we haven\u0026rsquo;t fully solved.\u0026rdquo;\u003c/em\u003e (DH-06)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eDifferential Adaptation among Patients and Staff\u003c/h2\u003e \u003cp\u003eAdaptation to the new system was not universal. A portion of patients, particularly older or from rural areas, struggled with new norms like appointments, while some staff exhibited resistance to changing long-held practices.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;About 30% of patients don\u0026rsquo;t understand and value the appointment system. Especially older patients or those from very rural areas, still come whenever they want. It disrupts the flow and challenges the principle of the standard for everyone.\u0026rdquo;\u003c/em\u003e (YY-01)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;A portion of the team still thinks, \u0026lsquo;The old way was fine, why change?\u0026rsquo; They struggle to see that managing HIV as a chronic disease for a growing population requires this new level of organization and professionalism.\u0026rdquo;\u003c/em\u003e (KM-01)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eThe Emotional Labor Burden\u003c/h2\u003e \u003cp\u003eA profound and persistent challenge was the enduring emotional and psychological toll of HIV care. While systemic efficiencies reduced administrative stress, the \u0026ldquo;heart-fatigue\u0026rdquo; from managing patient stigma, anxiety, and grief remained largely unaddressed by the support ecosystem.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The chaos is gone, so we\u0026rsquo;re less exhausted from that. But the \u0026lsquo;heart-fatigue\u0026rsquo; is still there\u0026mdash;carrying the patients\u0026rsquo; stories of stigma, managing their anxieties about aging with HIV, and confronting grief. This work sits in your heart. We have no formal, structured psychological supervision to process this.\u0026rdquo;\u003c/em\u003e (DH-02)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e This qualitative study draws on FGD to examine healthcare providers\u0026rsquo; perspectives regarding the implementation and impact of Standardized HIV Care Clinic in Yunnan Province, China. Our findings reveal that this initiative represents more than a simple procedural update; it is a systemic transformation that restructured workflows, deepened human interactions, and was fundamentally enabled by organizational support, all while navigating persistent challenges. The resulting conceptual model illustrated how structural and humanistic changes synergistically drive improvements in care quality and professional efficacy. This discussion interprets these findings within the broader context of health systems strengthening and chronic care management.\u003c/p\u003e \u003cp\u003eConsistent with models of healthcare quality improvement that emphasize both structural and process factors [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], our study identified workflow standardization as a core step. The implementation of clear protocols, appointment systems, and spatial redesign directly addressed the chaos of the prior model, creating a predictable environment necessary for higher-order care activities. This aligns with established principles of health service design where optimizing the \u0026ldquo;system\u0026rdquo; is a prerequisite for reliable, safe, and dignified care [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Beyond structure, a central finding was the critical role of human empowerment and interaction. The training in communication skills like Motivational Interviewing and the use of visual aids reflect an investment in the \u0026ldquo;soft technology\u0026rdquo; of care, which is increasingly recognized as vital for managing chronic conditions [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The concurrent transition of patients from passive recipients to active partners and the accompanying surge in provider efficacy underscore a dual imperative: durable chronic-disease management is predicated on the simultaneous empowerment of patients and clinicians[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Crucially, this transformation was not automatic. It was fueled by multifaceted organizational support, including leadership commitment, experiential training, and sanctioned flexibility. This highlights that successful health service innovation depends heavily on creating an enabling institutional environment that provides both resources and psychological safety for change [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The persistence of challenges like resource constraints and emotional burden further confirms that technical interventions alone are insufficient without addressing deeper systemic and workforce well-being issues [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur conceptual model contributes to the literature by proposing a dynamic structuration model for clinic-level health system improvement. It moves beyond listing facilitators and barriers to depict their dynamic interaction.The Synergy: The model posits that \u0026ldquo;System Redesign\u0026rdquo; and \u0026ldquo;Human Empowerment\u0026rdquo; are not sequential but concurrent and mutually reinforcing. For instance, a streamlined appointment system (a structural change) creates the time necessary for a motivational interview (a humanistic skill), while effective communication (a humanistic skill) ensures patient buy-in for the new system (structural change). This synergy resolves the \u0026ldquo;efficiency paradox\u0026rdquo;, demonstrating that investing in deeper care can co-exist with improved throughput when systemic waste is eliminated\u0026mdash;a finding supported by operations management research in healthcare[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] .The Essential Enabler: The model positions \u0026ldquo;Organizational Support\u0026rdquo; not as a background factor but as the essential fuel for both engines. This aligns with implementation science frameworks, such as the Consolidated Framework for Implementation Research, which emphasize the inner organizational setting as a critical determinant of implementation success [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].The Ongoing Context: By framing \u0026ldquo;challenges and barriers\u0026rdquo; as a continuous backdrop, the model realistically acknowledges that improvement is a journey, not a destination. It suggests that future gains may require different types of interventions, particularly those addressing workforce psychosocial support and inter-sectoral collaboration[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study calls for an integrated approach to investment: funding and policies must simultaneously shore up the \u0026ldquo;hardware\u0026rdquo; of care\u0026mdash;physical clinics, IT infrastructure\u0026mdash;and its \u0026ldquo;software,\u0026rdquo; namely communication training and psychosocial support for staff. Standardized protocols should be mandated in tandem with ongoing, experiential training and team-building that enable staff to bring those protocols to life [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].Building on the adaptive-intervention framework, flexible adaptation is best understood not as simple delegation, but as a principled sequence of decision rules. Successful implementation requires balancing fidelity to core model components with autonomy for local problem-solving. Leaders must actively champion the change, provide tangible resources, and create feedback mechanisms (like adjusted performance incentives) to sustain motivation [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe unresolved challenges point to clear priorities. Future initiatives must explicitly plan for: a) Workforce protection, including measures to address the specific emotional labor of HIV care to prevent burnout[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]; and b) Enhanced patient navigation, providing tailored support (e.g., through peer workers) to help vulnerable patients adapt to new systems, ensuring equity within standardization [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].The primary goal is to establish an integrated service delivery model within the standardized clinic. This model moves beyond exclusive HIV care to address the comprehensive health needs of people living with HIV, thereby enhancing care quality, optimizing resources, and reducing stigma through service integration[8,43].\u003c/p\u003e \u003cp\u003eThis study has limitations. Its focus on provider perspectives, while a strength in depth, means the patient voice is secondhand represented. The sample, though diverse across Yunnan, may not capture all regional variations in China. Furthermore, the cross-sectional design describes mechanisms and outcomes based on recall and perception; longitudinal research is needed to assess sustainability and quantifiable health outcomes. The study\u0026rsquo;s strengths lie in its rich qualitative data, rigorous analytical process with intercoder reliability checks, and the development of an integrative conceptual model derived directly from frontline experiences. By capturing the nuances of implementation from the perspective of those enacting the change, it provides practical insights often missed in purely outcome-focused evaluations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe standard HIV care clinics in Yunnan is a significant step toward sustainable, high-quality chronic HIV care. Our analysis demonstrates that its effectiveness stems from a dual focus on rationalizing care systems and empowering the people within them\u0026mdash;patients and providers alike. This transformation is sustainably powered by intentional organizational support. The persistent challenges, particularly around staff well-being and resource equity, chart the course for the next phase of health system strengthening. The proposed a dynamic structuration model offers a valuable framework for designing and evaluating similar chronic care service improvements in other contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e’\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003econtributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and study design by YZ, TL and LL. Data collection, including the conduct of interviews, and qualitative data analysis were performed by YZ, YZh, JCL, and LL. The manuscript was drafted by YZ and subsequently revised and critically reviewed by XD, TL and YL. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Yunnan Clinical Research Center for Infectious Disease (AIDS)( 202405AJ310002)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe full interview transcripts cannot be shared publicly to protect participant privacy. The semi-structured interview guide is available as supplementary files with this publication. Qualitative codebook will be available upon request on a case-by-case basis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Yunnan Provincial Infectious Disease Hospital (Ref:Ke2024050) . All participants provided written informed consent. Audio recordings were securely stored and anonymized during transcription.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYunnan Provincial Hospital of Infectious Disease/Yunnan AIDS Care Center, Kunming, China\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMu W, Patankar V, Kitchen S, Zhen A. Examining Chronic Inflammation, Immune Metabolism, and T Cell Dysfunction in HIV Infection. 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Front Public Health. 2023;11:1273720. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpubh.2023.1273720\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2023.1273720\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HIV Care, Clinic Standardization, Qualitative Study, Implementation, China","lastPublishedDoi":"10.21203/rs.3.rs-8586604/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8586604/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe global shift of HIV to a manageable chronic condition necessitates a transformation in care delivery from disease-centered approach to patient-centered, comprehensive management. In response, Yunnan Province has initiated the standardization of HIV care clinics. However, the frontline perspective on implementation remains a key gap, hindering insight into the real-world mechanisms of success and challenge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative study was conducted in Yunnan Province, China, between March and June 2025. Using maximum variation purposive sampling, we recruited 28 participants (including physicians, and case managers) from five hospitals at the provincial, prefectural, and county levels. Data were collected through five semi-structured focus group discussions. The audio-recorded discussions were transcribed verbatim and analyzed using the Framework Method.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study identified four core domains in the implementation of standardized HIV clinics through framework analysis: (1) Restructuring Workflow and Environment, which enhanced service efficiency and quality through coordinated procedural, spatial, and digital reorganization; (2) Deepening Patient‑Provider Interaction, shifting care from transactional exchanges to patient‑centered, relational communication; (3) Building Organizational Support and Team Capacity, realized through leadership endorsement, experiential training, and flexible adaptation; and (4) Navigating Persistent Challenges, including resource constraints, differential adaptation among patients and staff, and unaddressed emotional labor burden. These domains are dynamically linked: structured workflows enable higher‑quality interactions, while the trust built through these interactions in turn refines workflow details. Organizational support reinforces this cycle, driving the establishment and sustainment of clinic standardization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYunnan’s standardized HIV care clinic model demonstrates that effective, sustainable chronic care emerges from the dynamic interplay of system rationalization and human empowerment, offering a replicable framework for similar settings while underscoring the need to address persistent resource and well-being challenges.\u003c/p\u003e","manuscriptTitle":"Implementing Standardized HIV Care Clinics: A Qualitative Study from Healthcare Providers in Yunnan, China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 11:59:57","doi":"10.21203/rs.3.rs-8586604/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"14047829782270941516655861406301809320","date":"2026-03-02T10:11:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-24T15:21:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119906294812376210593716415551166023824","date":"2026-02-24T14:28:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-24T10:58:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-30T18:37:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-19T11:53:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T11:51:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-13T02:58:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ac983770-2e56-4e38-a721-af87dc84f081","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T11:59:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 11:59:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8586604","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8586604","identity":"rs-8586604","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}