Promoting HIV Testing by Men: A Discrete Choice Experiment to Elicit Preferences and Predict Uptake of Community-based Testing in Uganda

Village health team-delivered oral HIV self-testing increases linkage-to-care and antiretroviral-therapy initiation among men in Uganda

Targeted strategies are central to increasing HIV-status awareness and progress on the care cascade among men. We implemented Village-Health-Team (VHT)-delivered HIV self-testing (HIVST) among men in a peri-urban Ugandan district and assessed linkage to confirmatory-testing, antiretroviral-therapy (ART) initiation and HIV-status disclosure following HIVST. We conducted a prospective cohort study from November 2018 to June 2019 and enrolled 1628 men from 30-villages of Mpigi district. VHTs offered each participant one HIVST-kit and a linkage-to-care information leaflet. At baseline, we collected data on demographics, testing history and risk behavior. At one-month, we measured linkage to confirmatory-testing and HIV-status disclosure, and at three months ART-initiation if tested HIV-positive. We used Poisson regression generalized estimating equations to evaluate predictors of confirmatory-testing. We found that 19.8% had never tested for HIV and 43% had not tested in the last 12-months. After receiving HIVST-kits, 98.5% self-reported HIVST-uptake in 10-days, 78.8% obtained facility-based confirmation in 30-days of HIVST with 3.9% tested HIV-positive. Of the positives, 78.8% were newly diagnosed, 88% initiated ART and 57% disclosed their HIV-status to significant others. Confirmatory testing was associated with having a higher level of education and knowing a partner's HIV-status. VHT-delivered HIVST may be effective for boosting testing, ART-initiation and HIV-status disclosure among men.

A modelling framework for translating discrete choice experiment results into cost-effectiveness estimates: an application to designing tailored and scalable HIV and contraceptive services for adolescents in Gauteng, South Africa

INTRODUCTION

South African youth and adolescents face a high burden of (Sexually Transmitted Infections) STIs, HIV and unintended pregnancies, but uptake of services remains low. To address this, tailored and scalable interventions are urgently needed. We developed a framework to fill the gap and translate the impact of facility-level attributes into a cost-effectiveness analysis for increasing HIV/contraceptive service uptake in adolescents using a discrete choice experiment (DCE).

METHODS

We used a DCE (n = 805) conducted in Gauteng, South Africa, which found that staff attitude, confidentiality, Wi-Fi, subsidized food, afternoon hours and youth-only services were preferred attributes of health services. Based on this, we simulated the uptake of services adapted for these preferences. We divided preferences into modifiable attributes that could readily be adapted (e.g. Wi-Fi), and challenging to modify (more nuanced attributes that are more challenging to cost and evaluate): staff attitude and estimated the incremental change in the uptake of services using adapted services. Costs for modifiable preferences were estimated using data from two clinics in South Africa (2019 US$). We determined the incremental cost-effectiveness ratio (ICER) for additional adolescents using services of 15 intervention combinations, and report the results of interventions on the cost-effectiveness frontier.

RESULTS

Greatest projected impact on uptake was from friendly and confidential services, both of which were considered challenging to modify (18.5% 95% CI: 13.0%-24.0%; 8.4% 95% CI: 3.0%-14.0%, respectively). Modifiable factors on their own resulted in only small increases in expected uptake. (Food: 2.3% 95% CI: 4.0%-9.00%; Wi-Fi: 3.0% 95% CI: -4.0% to 10.0%; Youth-only services: 0.3% 95% CI: -6.0% to 7.0%; Afternoon services: 0.8% 95% CI: -6.0% to 7.0%). The order of interventions on the cost-effectiveness frontier are Wi-Fi and youth-only services (ICER US$7.01-US$9.78 per additional adolescent utilizing HIV and contraceptive services), Wi-Fi, youth-only services and food (ICER US$9.32-US$10.45), followed by Wi-Fi, youth-only services and extended afternoon hours (ICER US$14.46-US$43.63).

CONCLUSIONS

Combining DCE results and costing analyses within a modelling framework provides an innovative way to inform decisions on effective resource utilization. Modifiable preferences, such as Wi-Fi provision, youth-only services and subsidized food, have the potential to cost-effectively increase the proportion of adolescents accessing HIV and contraceptive services.

Preferences for accessing sexual health services among middle-aged and older adults in the UK: a study protocol for a discrete choice experiment using mixed methods

INTRODUCTION

Sexual health is essential for general health and well-being. Sexual health services for middle-aged and older adults are not prioritised and optimising available services for this population is often overlooked. Not much is known about preferences for accessing sexual health services among middle-aged and older people or level of satisfaction with current services. The aim of this study is to explore preferences for seeking sexual health services among middle-aged and older adults in the UK. This study will use discrete choice experiments (DCEs) including initial qualitative interviews followed by the survey, which have been used as a tool to explore preferences in various health service delivery.

METHODS AND ANALYSIS

The project will be carried out in two phases. First, we will conduct in-depth semi-structured interviews with 20-30 adults (aged 45+), including disabled people, and those from sexual minority groups resident in the UK. Interviews will explore indications, preferences and factors related to accessing sexual health services. Themes and subthemes emerging from the analysis of the interviews will then be used to design the choice sets and attribute level for the DCEs. For the second phase, for the DCEs, we will design choice sets composed of sexual health service delivery scenarios. The software Ngene will be used to develop the experimental design matrix for the DCE. We will use descriptive statistics to summarise the key sociodemographic characteristics of the study population. Multinomial logit, latent class and mixed logit models will be explored to assess sexual health service preferences and preference heterogeneity.

ETHICS AND DISSEMINATION

Ethical approval for both parts of this study was granted by the Research and Ethics Committee at the London School of Hygiene & Tropical Medicine. Findings from this study will be disseminated widely to relevant stakeholders via scheduled meetings, webinars, presentations and journal publications.

Changing attitudes towards HIV testing and treatment among three generations of men in Cameroon: a qualitative analysis using the Fogg Behavior Model

INTRODUCTION

Men are less likely than women to test for HIV and promptly initiate antiretroviral treatment, resulting in advanced HIV disease and increased mortality rates among them.

METHODS

In-depth interviews were conducted with men and leaders in the west and central regions of Cameroon. Men were recruited from existing community groups and stratified by age: 21-30 years, 31-40 years, and 41 years and older. Community leaders were recommended by the community dialogue structure chairman. Interviews were conducted using a semi-structured guide in English or French, depending on the participant's preference. Transcripts were coded in the MAXQDA v.12 software and analyzed using thematic analysis and by age group. The Fogg Behavior Model was used to gain a deeper understanding of the different perceptions across all age groups.

RESULTS

Younger men (21-30 years) were generally more accepting of HIV testing, as it had become normative behavior. Although financial barriers could limit access, free testing was mentioned as a prompt to initiate HIV testing. The middle age men (31-40 years) had the most concerns about HIV testing interrupting their work day and recommended increasing testing locations and hours. The older men (41 + years) were the least motivated to get tested, citing worries about the impact on their social standing within the community. All age groups reported being motivated to begin treatment if they were found to be HIV-positive. Participants also provided insights regarding community HIV testing and treatment messaging. Younger and older men preferred to hear directly from qualified health professionals, but younger men noted that social media, radio, and TV could be utilized. Middle age men also identified TV and radio as effective mediums, if door-to-door messaging was not an option.

CONCLUSIONS

The study highlights important considerations when planning future information-sharing activities for HIV testing and treatment. Since lived experiences differ across generations and societal roles continue to change, not only should the content of messages differ among the generations, but the means of communication must also be considered to ensure the messages are conveyed through a trusted source.

The effectiveness, feasibility and acceptability of HIV service delivery at private pharmacies in sub-Saharan Africa: a scoping review

INTRODUCTION

Private pharmacies are an understudied setting for differentiated delivery of HIV services that may address barriers to clinic-delivered services, such as stigma and long wait times. To understand the potential for pharmacy-delivered HIV services in sub-Saharan Africa, we conducted a scoping review of the published and grey literature.

METHODS

Using a modified Cochrane approach, we searched electronic databases through March 2022 and HIV conference abstracts in the past 5 years for studies that: (1) focused on the delivery of HIV testing, antiretroviral therapy (ART) and/or pre-exposure prophylaxis (PrEP) at private pharmacies in sub-Saharan Africa; (2) reported on effectiveness outcomes (e.g. HIV incidence) or implementation outcomes, specifically feasibility and/or acceptability; and (3) were published in English. Two authors identified studies and extracted data on study setting, population, design, outcomes and findings by HIV service type.

RESULTS AND DISCUSSION

Our search identified 1646 studies. After screening and review, we included 28 studies: seven on HIV testing, nine on ART delivery and 12 on PrEP delivery. Most studies (n = 16) were conducted in East Africa, primarily in Kenya. Only two studies evaluated effectiveness outcomes; the majority (n = 26) reported on feasibility and/or acceptability outcomes. The limited effectiveness data (n = 2 randomized trials) suggest that pharmacy-delivered HIV services can increase demand and result in comparable clinical outcomes (e.g. viral load suppression) to standard-of-care clinic-based models. Studies assessing implementation outcomes found actual and hypothetical models of pharmacy-delivered HIV services to be largely feasible (e.g. high initiation and continuation) and acceptable (e.g. preferable to facility-based models and high willingness to pay/provide) among stakeholders, providers and clients. Potential barriers to implementation included a lack of pharmacy provider training on HIV service delivery, costs to clients and providers, and perceived low quality of care.

CONCLUSIONS

The current evidence suggests that pharmacy-delivered HIV services may be feasible to implement and acceptable to clients and providers in parts of sub-Saharan Africa. However, limited evidence outside East Africa exists, as does limited evidence on the effectiveness of and costs associated with pharmacy-delivered HIV services. More research of this nature is needed to inform the scale-up of this new differentiated service delivery model throughout the region.

Divergent preferences for enhanced HIV testing options among high-risk populations in northern Tanzania: a short report

To achieve the UNAIDS target of diagnosing 95% of all persons living with HIV, enhanced HIV testing services with greater attractional value need to be developed and implemented. We conducted a discrete choice experiment (DCE) to quantify preferences for enhanced HIV testing features across two high-risk populations in the Kilimanjaro Region in northern Tanzania. We designed and fielded a survey with 12 choice tasks to systematically recruited female barworkers and male mountain porters. Key enhanced features included: testing availability on every day of the week, an oral test, integration of a general health check or an examination for sexually transmitted infections (STI) with HIV testing, and provider-assisted confidential partner notification in the event of a positive HIV test result. Across 300 barworkers and 440 porters surveyed, mixed logit analyses of 17,760 choices indicated strong preferences for everyday testing availability, health checks, and STI examinations. Most participants were averse to oral testing and confidential partner notification by providers. Substantial preference heterogeneity was observed within each risk group. Enhancing HIV testing services to include options for everyday testing, general health checks, and STI examinations may increase the appeal of HIV testing offers to high-risk populations.Trial registration: ClinicalTrials.gov identifier: NCT02714140.

Patient preferences for facility-based management of hypertension and diabetes in rural Uganda: a discrete choice experiment

OBJECTIVE

To explore how respondents with common chronic conditions-hypertension (HTN) and diabetes mellitus (DM)-make healthcare-seeking decisions.

SETTING

Three health facilities in Nakaseke District, Uganda.

DESIGN

Discrete choice experiment (DCE).

PARTICIPANTS

496 adults with HTN and/or DM.

MAIN OUTCOME MEASURES

Willingness to pay for changes in DCE attributes: getting to the facility, interactions with healthcare providers, availability of medicines for condition, patient peer-support groups; and education at the facility.

RESULTS

Respondents were willing to pay more to attend facilities that offer peer-support groups, friendly healthcare providers with low staff turnover and greater availabilities of medicines. Specifically, we found the average respondent was willing to pay an additional 77 121 Ugandan shillings (UGX) for facilities with peer-support groups over facilities with none; and 49 282 UGX for 1 month of medicine over none, all other things being equal. However, respondents would have to compensated to accept facilities that were further away or offered health education. Specifically, the average respondent would have to be paid 3929 UGX to be willing to accept each additional kilometre they would have to travel to the facilities, all other things being equal. Similarly, the average respondent would have to be paid 60 402 UGX to accept facilities with some health education, all other things being equal.

CONCLUSIONS

Our findings revealed significant preferences for health facilities based on the availability of medicines, costs of treatment and interactions with healthcare providers. Understanding patient preferences can inform intervention design to optimise healthcare service delivery for patients with HTN and DM in rural Uganda and other low-resource settings.

Demonstration and acceptability of a safer conception intervention for men with HIV in South Africa (Preprint)

Background

Many men with HIV (MWH) want to have children. HIV viral suppression minimizes sexual HIV transmission risks while allowing for conception and optimization of the health of men, their partners, and their infants.

Objective

This study developed and evaluated the feasibility and acceptability of an intervention to promote serostatus disclosure, antiretroviral therapy (ART) uptake and adherence, and viral suppression among MWH who want to have children in South Africa.

Methods

We developed a safer conception intervention (Sinikithemba Kwabesilisa or We give hope to men) to promote viral suppression via ART uptake and adherence, HIV serostatus disclosure, and other safer conception strategies for MWH in South Africa. Through 3 counseling and 2 booster sessions over 12 weeks, we offered education on safer conception strategies and aided participants in developing a safer conception plan. We recruited MWH (HIV diagnosis known for >1 month), not yet accessing ART or accessing ART for <3 months, in a stable partnership with an HIV-negative or unknown-serostatus woman, and wanting to have a child in the following year. We conducted an open pilot study to evaluate acceptability based on patient participation and exit interviews and feasibility based on recruitment and retention. In-depth exit interviews were conducted with men to explore intervention acceptability. Questionnaires collected at baseline and exit assessed disclosure outcomes; CD4 and HIV-RNA data were used to evaluate preliminary impacts on clinical outcomes of interest.

Results

Among 31 eligible men, 16 (52%) enrolled in the study with a median age of 29 (range 27-44) years and a median time-since-diagnosis of 7 months (range 1 month to 9 years). All identified as Black South African, with 56% (9/16) reporting secondary school completion and 44% (7/16) reporting full-time employment. Approximately 44% (7/16) of participants reported an HIV-negative (vs unknown-serostatus) partner. Approximately 88% (14/16) of men completed the 3 primary counseling sessions. In 11 exit interviews, men reported personal satisfaction with session content and structure while also suggesting that they would refer their peers to the program. They also described the perceived effectiveness of the intervention and self-efficacy to benefit. Although significance testing was not conducted, 81% (13/16) of men were taking ART at the exit, and 100% (13/13) of those on ART were virally suppressed at 12 weeks. Of the 16 men, 12 (75%) reported disclosure to pregnancy partners.

Conclusions

These preliminary data suggest that safer conception care is acceptable to men and has the potential to reduce HIV incidence among women and their children while supporting men’s health. Approximately half of the men who met the screening eligibility criteria were enrolled. Accordingly, refinement to optimize uptake is needed. Providing safer conception care and peer support at the community level may help reach men.

Trial Registration

ClinicalTrials.gov NCT03818984; https://clinicaltrials.gov/ct2/show/NCT03818984

International Registered Report Identifier (IRRID)

RR2-https://doi.org/10.1007/s10461-017-1719-4

Preferences of patients regarding community pharmacy services: A discrete choice experiment

BACKGROUND

The community pharmacy profession is in transition, with emphasis on the provision of cognitive pharmaceutical services (CPS). In contrast, previous research showed that the general public prefers more convenience related services. However, this was based on currently available services and not on innovative services.

OBJECTIVE

To identify patients' preferences regarding innovative pharmacy services and whether they tend towards convenience related or CPS.

DESIGN

Online survey using a discrete choice experiment (DCE).

PARTICIPANTS

Participants were from the AMP pharmacy patient panel.

MAIN OUTCOME MEASURES

Preferences (utility scores) and the identification of specific classes (latent class analysis).

RESULTS

In total 2462 panel members (27.3%) filled out the completed the online DCE questionnaire. The majority of participants were male (54.1%) with an average age of 65.3 years and used on average 4.6 medicines. Four patient classes were distinguished based on preferences for services. Highly preferred were an online mediation record, prescription drugs for minor ailments without a doctors' prescription and clinical testing with diagnosis by the pharmacist.

DISCUSSION AND CONCLUSION

The majority of participants tend towards a more CPS focused approach by the community pharmacist. Patients visiting community pharmacies can have a diverging set of preferences regarding services being provided. In daily practice, community pharmacists should provide both convenience and CPS related services to address this diverse set of preferences.

Implementation outcomes of HIV self-testing in low- and middle- income countries: A scoping review

INTRODUCTION

HIV self-testing (HIV-ST) is an effective means of improving HIV testing rates. Low- and middle-income countries (LMIC) are taking steps to include HIV-ST into their national HIV/AIDS programs but very few reviews have focused on implementation in LMIC. We performed a scoping review to describe and synthesize existing literature on implementation outcomes of HIV-ST in LMIC.

METHODS

We conducted a systematic search of Medline, Embase, Global Health, Web of Science, and Scopus, supplemented by searches in HIVST.org and other grey literature databases (done 23 September 2020) and included articles if they reported at least one of the following eight implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, cost, penetration, or sustainability. Both quantitative and qualitative results were extracted and synthesized in a narrative manner.

RESULTS AND DISCUSSION

Most (75%) of the 206 included articles focused on implementation in Africa. HIV-ST was found to be acceptable and appropriate, perceived to be convenient and better at maintaining confidentiality than standard testing. The lack of counselling and linkage to care, however, was concerning to stakeholders. Peer and online distribution were found to be effective in improving adoption. The high occurrence of user errors was a common feasibility issue reported by studies, although, diagnostic accuracy remained high. HIV-ST was associated with higher program costs but can still be cost-effective if kit prices remain low and HIV detection improves. Implementation fidelity was not always reported and there were very few studies on, penetration, and sustainability.

CONCLUSIONS

Evidence supports the acceptability, appropriateness, and feasibility of HIV-ST in the LMIC context. Costs and user error rates are threats to successful implementation. Future research should address equity through measuring penetration and potential barriers to sustainability including distribution, cost, scale-up, and safety.

HIV Self-Testing Uptake and Intervention Strategies Among Men in Sub-Saharan Africa: A Systematic Review

Background: HIV testing is an essential gateway to HIV prevention and treatment services. However, HIV testing uptake remains low among men due to stigma, discrimination, and confidentiality concerns. HIV self-testing (HIVST) is an alternative HIV testing method that can address many of these barriers for men. We conducted a systematic review to examine HIVST uptake and intervention strategies among Men in Sub-Saharan Africa.

Methods: We used a systematic approach to survey literature published from January 2010 to June 2020 using five electronic databases (PubMed-Medline, CINAHL Complete, PsychINFO, Google Scholar, and Web of Science) and a manual search. Studies were included if they were peer-reviewed, published in English, and examined HIVST willingness, uptake, and/or linkage to care and included men in Sub-Saharan Africa.

Results: Sixty-three articles related to HIVST were reviewed. Of the included articles, 37 discussed HIVST uptake/acceptability and 24 discussed intervention strategies. Both oral swab and finger-prick methods had high acceptability with ease of access and availability of the test cited as important by men. Free HIVST kits were preferred by men. Secondary distribution of kits via peers, sexual partners, and female sex workers were successful.

Conclusion: HIV self-testing is highly acceptable to men. More efforts are needed to develop policies to implement HIVST programs targeting men in Sub-Saharan Africa, including a focus on linkage to care in sub-Saharan Africa. Future interventions should directly target men independently in tandem with using peers and their romantic partners to promote self-testing among men in sub-Saharan Africa. HIVST kit distribution strategies should be combined with services that can offer confirmatory tests and counseling for men as well as linkage to care.

Shortening "the Road" to Improve Engagement with HIV Testing Resources: A Qualitative Study Among Stakeholders in Rural Uganda

In HIV-endemic areas, traditional healers are frequently used with, or instead of, biomedical resources for health care needs. Studies show healers are interested in and capable of supporting patients in the HIV care cascade. However, adults who receive care from healers have low engagement with HIV services. To achieve epidemic control, we must understand gaps between the needs of HIV-endemic communities and the potential for healers to improve HIV service uptake. This study's objective was to characterize stakeholder perspectives on barriers to HIV testing and approaches to mitigate barriers in a medically pluralistic, HIV-endemic region. This study was conducted in Mbarara District, a rural area of southwestern Uganda with high HIV prevalence. Participants included HIV clinical staff, traditional healers, and adults receiving care from healers. Fifty-six participants [N = 30 females (52%), median age 40 years (interquartile range, 32-51.5)] were recruited across three stakeholder groups for minimally structured interviews. Themes were identified using an inductive, grounded theory approach and linked together to create a framework explaining stakeholder perspectives on HIV testing. Stakeholders described the "road" to HIV testing as time-consuming, expensive, and stigmatizing. All agreed healers could mitigate barriers by delivering HIV testing at their practices. Collaborations between biomedical and traditional providers were considered essential to a successful healer-delivered HIV testing program. This work describes a novel approach to "shorten the road" to HIV testing, suggesting that traditional healer-delivered HIV testing holds promise to expand uptake of testing among communities with limited access to existing programs.

Eliciting Preferences for HIV Prevention Technologies: A Systematic Review

Background

Many human immunodeficiency virus (HIV) prevention technologies (pre-exposure prophylaxis, microbicides, vaccines) are available or in development. Preference elicitation methods provide insight into client preferences that may be used to optimize products and services. Given increased utilization of such methods in HIV prevention, this article identifies and reviews these methods and synthesizes their application to HIV prevention technologies.

Methods

In May 2020, we systematically searched peer-reviewed literature in PubMed, CINAHL, and Web of Science for studies employing quantitative preference elicitation methods to measure preferences for HIV prevention technologies among populations of any age, sex, or location. Quality assessment used an existing checklist (PREFS) and a novel adaptation of the Newcastle–Ottawa Scale (PROSPERO #CRD42018087027).

Results

We screened 5022 titles and abstracts, reviewed 318 full texts, and included 84 studies. Common methods employed were discrete-choice experiment (33%), conjoint analysis (25%), and willingness-to-participate/try/accept (21%). Studies were conducted in 25 countries and had a mean of 768 participants (range = 26–7176), two-thirds of them male. Common HIV prevention technologies included pre-exposure prophylaxis (23%), voluntary testing and counseling (19%), HIV self-testing (17%), vaccines (15%), and topical microbicides (9%). Most attributes focused on product design (side effects, frequency), service design (provider type, location), acceptability or willingness to accept/pay; results are summarized in these categories, by prevention type. Mean quality-adapted Newcastle–Ottawa Scale score was 4.5/8 (standard deviation = 2.1) and mean PREFS scores was 3.47/5 (standard deviation = 0.81).

Conclusions

This review synthesizes extant literature on quantitative measurement of preferences for HIV prevention technologies. This can enable practitioners to improve prevention products and interventions, and ultimately reduce HIV incidence.

Prevalence, associated factors and perspectives of HIV testing among men in Uganda

BACKGROUND

Despite overall increase in HIV testing, more men than women remain untested. In 2018, 92% of Ugandan women but only 67% of men had tested for HIV. Understanding men's needs and concerns for testing could guide delivery of HIV testing services (HTS) to them. We assessed the prevalence of testing, associated factors and men's perspectives on HIV testing in urban and peri-urban communities in Central Uganda.

METHODS AND FINDINGS

We conducted a parallel-convergent mixed-methods study among men in Kampala and Mpigi districts from August to September 2018. Using two-stage sampling, we selected 1340 men from Mpigi. We administered a structured questionnaire to collect data on HIV testing history, socio-demographics, self-reported HIV risk-related behaviors, barriers and facilitators to HIV testing. We also conducted 10 focus-groups with men from both districts to learn their perspectives on HIV testing. We used modified Poisson regression to assess factors associated with HIV testing and inductive thematic analysis to identify barriers and facilitators. Though 84.0% of men reported having tested for HIV, only 65.7% had tested in the past 12-months despite nearly all (96.7%) engaging in at least one HIV risk-related behavior. Men were more likely to have tested if aged 25-49 years, Catholic, with secondary or higher education and circumcised. Being married was associated with ever-testing while being widowed or divorced was associated with testing in past 12-months. Men who engaged in HIV risk-related behavior were less likely to have tested in the past 12-months. Qualitative findings showed that men varied in their perspectives about the need for testing, access to HTS and were uncertain of HIV testing and its outcomes.

CONCLUSIONS

Recent HIV testing among men remains low. Modifying testing strategies to attract men in all age groups could improve testing uptake, reduce gender disparity and initiate risk reduction interventions.