One size does not fit all: HIV testing preferences differ among high-risk groups in Northern Tanzania

Preference heterogeneity for HIV pre-exposure prophylaxis care among gay, bisexual, and other men who have sex with men in the United States: a large discrete choice experiment

Background

PrEP uptake among Black and Latino gay, bisexual, and other men who have sex with men (GBM) remains low in the United States. The design and implementation of PrEP delivery programs that incorporate the preferences of Black and Latino GBM may overcome barriers to uptake. We aimed to identify preferences for PrEP care among high-priority GBM in the U.S. with a large discrete choice experiment.

Methods

We conducted two discreet choice experiments (DCE) to elicit care preferences for (1) Starting PrEP and (2) Continuing PrEP care among GBM clinically indicated for PrEP. The DCE web-based survey was nested in a longitudinal cohort study of GBM in the U.S., implemented with video and audio directions among 16-49 year-old participants, not using PrEP, and verified to be HIV-negative. All participants were presented with 16 choice sets, with choices determined by BLGBM and PrEP implementation stakeholders. We calculated overall utility scores and relative importance and used latent class analyses (LCA) to identify classes within the Starting and Continuing PrEP DCE. Multivariable analysis was performed to identify factors associated with class membership.

Findings

Among 1514 participants, mean age was 32 years; 46·5% identified as Latino, 21·4% Black, and 25·2 White; 37·5% had an income less than USD $20,000. Two latent classes were identified for Starting PrEP: Class 1 (n=431 [28·5%]) was driven by preference for more traditional in-person care, and Class 2 (n=1083 [71·5%]) preferred flexible care options and on-demand PrEP. In a multivariable model, having a sexual health doctor (adjusted OR 0·7, CI 0·5, 0·9), having a primary care provider (OR 0·7,CI 0·5, 0·9, p= 0·023), and concerns over PrEP side effects (OR 1·1, CI 1·0,1·2, p= 0·003) were all associated with class membership.

Interpretation

The different preferences identified for PrEP care indicate the need for diverse care and formulation choices to improve PrEP uptake and persistence. Addressing these preferences and understanding the factors that shape them can inform the implementation of programs that increase PrEP uptake.

Mobile Phone-Based Confidential Social Network Referrals for HIV Testing (CONSORT): Protocol for a Randomized Controlled Trial

BACKGROUND

Critical to efforts to end the HIV epidemic is the identification of persons living with HIV who have yet to be diagnosed and engaged in care. Expanded HIV testing outreach efforts need to be both efficient and ambitious, targeting the social networks of persons living with HIV and those at above-average risk of undiagnosed HIV infection. The ubiquity of mobile phones across many high HIV prevalence settings has created opportunities to leverage mobile health (mHealth) technologies to engage social networks for HIV testing outreach, prevention, and treatment.

OBJECTIVE

The purpose of this study is to evaluate the acceptability and efficacy of a novel mHealth intervention, "Confidential Social Network Referrals for HIV Testing (CONSORT)," to nudge at-risk individuals to test for HIV using SMS text messages.

METHODS

We will conduct the CONSORT study in Moshi, Tanzania, the commercial center and administrative capital of the Kilimanjaro Region in northern Tanzania. After qualitative formative work and pilot testing, we will enroll 400 clients presenting for HIV counseling and testing and 200 persons living with HIV and receiving care at HIV care and treatment centers as "inviters" into a randomized controlled trial. Eligible participants will be aged 18 years or older and live, work, or regularly receive care in Moshi. We will randomize inviters into 1 of 2 study arms. All inviters will be asked to complete a survey of their HIV testing and risk behaviors and to think of social network contacts who would benefit from HIV testing. They will then be asked to whom they would prefer to extend an HIV testing invitation in the form of a physical invitation card. Arm 1 participants will also be given the opportunity to extend CONSORT invitations in the form of automated confidential SMS text messages to any of their social network contacts or "invitees." Arm 2 participants will be offered physical invitation cards alone. The primary outcome will be counselor-documented uptake of HIV testing by invitees within 30 days of inviter enrollment. Secondary outcomes will include the acceptability of CONSORT among inviters, the number of new HIV diagnoses, and the HIV risk of invitees who present for testing.

RESULTS

Enrollment in the randomized controlled trial is expected to start in September 2024. The findings will be disseminated to stakeholders and published in peer-reviewed journals.

CONCLUSIONS

If CONSORT is acceptable and effective for increasing the uptake of HIV testing, given the minimal costs of SMS text reminders and the potential for exponential but targeted growth using chain referrals, it may shift current practices for HIV testing programs in the area.

TRIAL REGISTRATION

ClincalTrials.gov NCT05967208; https://clinicaltrials.gov/study/NCT05967208.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/55068.

Improving care engagement for mobile people living with HIV in rural western Kenya

BACKGROUND

Antiretroviral therapy (ART) assures major gains in health outcomes among people living with HIV, however, this benefit may not be realized by all due to care interruptions. Mobile populations comprise a subgroup that is likely to have sub-optimal care engagement, resulting in discontinuation of ART. We sought to evaluate the barriers to care engagement among highly mobile individuals living with HIV and explore options aimed at improving engagement in care for this group.

METHODS

Qualitative in-depth interviews were conducted in 2020 among a purposive sample of twelve persons living with HIV and eight health care providers in western Kenya, within a mixed methods study of mobility in communities participating in the SEARCH trial (NCT01864603). We explored the barriers to care engagement among mobile individuals living with HIV and explored different options aimed at enhancing care engagement. These included options such as a coded card containing treatment details, alternative drug packaging to conceal drug identity, longer refills to cover travel period, wrist bands with data storage capability to enable data transfer and "warm handoff" by providers to new clinics upon transfer. Data were inductively analyzed to understand the barriers and acceptability of potential interventions to address them.

RESULTS

Stigma and lack of disclosure, rigid work schedules, and unpredictability of travel were major barriers to care engagement for highly mobile individuals living with HIV. Additionally, lack of flexibility in clinic schedules and poor provider attitude were identified as health-system-associated barriers to care engagement. Options that enhance flexibility, convenience and access to care were viewed as the most effective means of addressing the barriers to care by both patients and providers. The most preferred option was a coded card with treatment details followed by alternative drug packaging to conceal drug identity due to stigma and longer refills to cover travel periods.

CONCLUSION

Highly mobile individuals living with HIV desire responsive, flexible, convenient and patient-centered care delivery models to enhance care engagement. They embraced simple health delivery improvements such as coded cards, alternative drug packaging and longer refills to address challenges of mobility.

Patient preferences and willingness-to-pay for community pharmacy-led Medicare Part D consultation services: A discrete choice experiment

INTRODUCTION

Community pharmacies currently offer Medicare Part D consultation services, often at no-cost. Despite facilitating plan-switching behavior, identifying potential cost-savings, and increasing medication adherence, patient uptake of these services remains low.

OBJECTIVES

To investigate patient preferences for specific service-offering attributes and marginal willingness-to-pay (mWTP) for an enhanced community pharmacy Medicare Part D consultation service.

METHODS

A discrete choice experiment (DCE) guided by the SERVQUAL framework was developed and administered using a national online survey panel. Study participants were English-speaking adults (≥65 years) residing in the United States enrolled in a Medicare Part D or Medicare Advantage plan and had filled a prescription at a community pharmacy within the last 12 months. An orthogonal design resulted in 120 paired-choice tasks distributed equally across 10 survey blocks. Data were analyzed using mixed logit and latent class models.

RESULTS

In total, 540 responses were collected, with the average age of respondents being 71 years. The majority of respondents were females (60%) and reported taking four or more prescription medication (51%). Service attribute levels with the highest utility were: 15-min intervention duration (0.392), discussion of services + a follow-up phone call (0.069), in-person at the pharmacy (0.328), provided by a pharmacist the patient knew (0.578), and no-cost (3.382). The attribute with the largest mWTP value was a service provided by a pharmacist the participant knew ($8.42). Latent class analysis revealed that patient preferences for service attributes significantly differed by gender and difficulty affording prescription medications.

CONCLUSIONS

Quantifying patient preference using discrete choice methodology provides pharmacies with information needed to design service offerings that balance patient preference and sustainability. Pharmacies may consider providing interventions at no-cost to subsets of patients placing high importance on a service cost attribute. Further, patient preference for 15-min interventions may inform Medicare Part D service delivery and facilitate service sustainability.

Acceptability of serosurveys in southern Zambia: data collector and caregiver perspectives

Background

Factors associated with whether individuals choose to participate in serosurveys are not well understood. Understanding perceptions from multiple perspectives, including the perspectives of both data collectors and participants, through a holistic model such as the socio-ecological model contextualizes individual, interpersonal, and structural level influences on survey research participation. We used a multiple methods approach to characterize reasons for serosurvey participation in communities in Southern Province, Zambia where a serosurvey was conducted in 2016.

Methods

The first phase conducted focus group discussions and in-depth interviews with 24 data collectors who participated in a measles-rubella serosurvey in 2016. The second phase surveyed 34 caregivers at health facilities to identify barriers and facilitators to serosurvey participation. Emergent themes were then classified into a socio-ecological model using individual, interpersonal, and structural level constructs.

Results

Common themes emerged from data collectors as well as caregivers surveyed. At the individual level, providing incentives was a facilitator, and some religious beliefs were described as a barrier to serosurvey participation. At the interpersonal level, family dynamics and community peer influences could help or hinder serosurvey participation. Community health workers were consistently named as facilitators of participation. At the structural level, concerns about specimen collection, who was selected for serosurveys, and not receiving test results arose as potential barriers. The most frequently reported facilitator was provision of information about the purpose of the serosurvey (85% of respondents). The most frequently reported barrier was lack of clarity regarding use of their blood specimen (53% of respondents). For specimen collection type, caregivers consistently preferred finger prick blood collection over both venous blood draw and oral swabs.

Conclusion

Serosurvey participation was deemed acceptable to most study participants. The socio-ecological model revealed barriers and facilitators for participation to guide strategies to improve participation which can be applied to ongoing serosurveys for SARS-CoV-2. Serosurveys should continue to develop engagement plans to provide information about blood collection ahead of the serosurvey and communicate the objectives of such studies through trusted sources such as community health workers and traditional leaders.

Feasibility, Acceptability, and Potential Cost-Effectiveness of a Novel Mobile Phone Intervention to Promote Human Immunodeficiency Virus Testing Within Social Networks in Tanzania

ABSTRACT

Among 145 individuals surveyed in Tanzania, 42% indicated willingness to test for human immunodeficiency virus in response to a confidential, phone-based text message. On average, participants were likely to provide contact information for 1.5 members of their social networks, suggesting high feasibility and moderate acceptability of a novel mHealth human immunodeficiency virus testing intervention.

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.

Acceptability and perceptions of HIV oral self-testing across settings: A comparative qualitative study among Dominican and Tanzanian female sex workers

Rapid oral HIV self-tests (HIVST) have potential to increase the proportion of people who know their HIV status, especially among stigmatised populations. This study was embedded in two cohorts of female sex workers (FSW) in the Dominican Republic (DR) and Tanzania. Qualitative interviews with 40 FSW were conducted to explore perceived acceptability of HIVST. Interviews were analysed using inductive and deductive thematic coding. Emergent themes were organised by socio-ecological framework levels. FSW in both settings responded positively to the ease of use of HIVST but questioned test accuracy due to the use of saliva rather than blood. FSW in the DR had a more cautious response, while women in Tanzania had favourable perceptions expressing eagerness to use it. At the individual level, themes shaping participants' interest included autonomy, HIV risk perception, and emotional well-being for those with reactive test results, and self-efficacy. At the interpersonal level, privacy, confidentiality, sex work and HIV stigma and social support were salient. Structural level themes focused on health systems including linkages to HIV treatment, provider roles, and access (cost, travel, distribution). Understanding FSW's perceptions and acceptability of HIVST is essential to its integration into health systems and programmes using a community-driven approach.

Preferences for HIV Testing Services and HIV Self-Testing Distribution Among Migrant Gay, Bisexual, and Other Men Who Have Sex With Men in Australia

Background

In Australia, undiagnosed HIV rates are much higher among migrant gay, bisexual, or other men who have sex with men (GBMSM) than Australian-born GBMSM. HIV self-testing is a promising tool to overcome barriers to HIV testing and improve HIV testing uptake among migrant GBMSM. We compared the preferences for HIV testing services, including HIV self-testing, among migrant and Australian-born GBMSM.

Methods

Preferences were assessed via two discrete choice experiments (DCEs). Participants were recruited between December 2017 and January 2018 using online and offline advertising and randomly assigned to complete one of two online DCE surveys. Migrant GBMSM were classified as being born in a country with a reciprocal healthcare agreement (RHCA) with Australia (providing free or subsided health care) or not. Latent class analysis and mixed logit models were used to explore heterogeneity in preferences.

Findings

We recruited 1,606 GBMSM, including 583 migrant men of whom 419 (72%) were born in non-RHCA countries. Most participants preferred a free or cheap oral test with higher accuracy and a shorter window period to facilitate early detection of infections. Cost was more important for men born in non-RHCA countries than for men from RHCA countries or Australia. All groups preferred accessing kits through online distributers or off the shelf purchasing from pharmacies. Men born in RHCA countries least preferred accessing HIV self-testing kits from a medical clinic, while more than half of men from non-RHCA countries most preferred sourcing kits from a clinic. Sex-on-premises venues were the least preferred location to access test kits among all groups. In addition, two latent class analyses explored heterogeneity in preferences among men from non-RHCA countries and we found four latent classes for HIV testing services and two latent classes for HIVST distribution.

Interpretation

Our findings emphasise the need for high-performing and low-cost HIV self-testing kits that are accessible from a variety of distribution points as a component of Australia's HIV response, especially for those who do not have access to free or subsidised health care in Australia.

A discrete choice experiment investigating HIV testing preferences in South Africa

BACKGROUND

South Africa (SA) has the world's highest burden of HIV infection, with an estimated 13.7% of the population living with HIV (PLWH/Persons Living With HIV). The early identification of PLWH and rapid engagement of them in HIV treatment are indispensable tools in the fight against HIV transmission. Understanding client preferences for HIV testing may help improve uptake. This study aimed to elicit client preferences for key characteristics of HIV testing options.

METHODS

A discrete-choice experiment (DCE) was conducted among individuals presenting for HIV testing at two public primary healthcare facilities in Cape Town, South Africa. Participants were asked to make nine choices between two unlabeled alternatives that differed in five attributes, in line with previous DCEs conducted in Tanzania and Colombia: testing availability, distance from the testing center, method for obtaining the sample, medication availability at testing centers, and confidentiality. Data were analyzed using a random parameter logit model.

RESULTS

A total of 206 participants agreed to participate in the study, of whom 199 fully completed the choice tasks. The mean age of the participants was 33.6 years, and most participants were female (83%). Confidentiality was the most important attribute, followed by distance from the testing center and the method of obtaining a sample. Patients preferred finger prick to venipuncture as a method for obtaining the sample. Medication availability at the testing site was also preferred over a referral to an HIV treatment center for a positive HIV test. There were significant variations in preferences among respondents.

CONCLUSION

In addition to accentuating the importance of confidentiality, the method for obtaining the sample and the location of sites for collection of medication should be considered in the testing strategy. The variations in preferences within target populations should be considered in identifying optimal testing strategies.

Preferences for transitional HIV care among people living with HIV recently released from prison in Zambia: a discrete choice experiment

Introduction

No studies from sub‐Saharan Africa have attempted to assess HIV service delivery preferences among incarcerated people living with HIV as they transition from prisons to the community (“releasees”). We conducted a discrete choice experiment (DCE) to characterize releasee preferences for transitional HIV care services in Zambia to inform the development of a differentiated service delivery model to promote HIV care continuity for releasees.

Methods

Between January and October 2019, we enrolled a consecutive sample of 101 releasees from a larger cohort prospectively following 296 releasees from five prisons in Zambia. We administered a DCE eliciting preferences for 12 systematically designed choice scenarios, each presenting three hypothetical transitional care options. Options combined six attributes: (1) clinic type for post‐release HIV care; (2) client focus of healthcare workers; (3) transitional care model type; (4) characteristics of transitional care provider; (5) type of transitional care support; and (6) HIV status disclosure support. We analysed DCE choice data using a mixed logit model, with coefficients describing participants’ average (“mean”) preferences for each option compared to the standard of care and their distributions describing preference variation across participants.

Results

Most DCE participants were male (n = 84, 83.2%) and had completed primary school (n = 54, 53.5%), with 29 (28.7%) unemployed at follow‐up. Participants had spent an average of 8.2 months in the community prior to the DCE, with 18 (17.8%) reporting an intervening episode of re‐incarceration. While we observed significant preference variation across participants (p < 0.001 for most characteristics), releasees were generally averse to clinics run by community‐based organizations versus government antiretroviral therapy clinics providing post‐release HIV care (mean preference = –0.78, p < 0.001). On average, releasees most preferred livelihood support (mean preference = 1.19, p < 0.001) and HIV care support (mean preference = 1.00, p < 0.001) delivered by support groups involving people living with HIV (mean preference = 1.24, p < 0.001).

Conclusions

We identified preferred characteristics of transitional HIV care that can form the basis for differentiated service delivery models for prison releasees. Such models should offer client‐centred care in trusted clinics, provide individualized HIV care support delivered by support groups and/or peer navigators, and strengthen linkages to programs providing livelihood support.

What factors influence HIV testing? Modeling preference heterogeneity using latent classes and class-independent random effects

Efforts to eliminate the HIV epidemic will require increased HIV testing rates among high-risk populations. To inform the design of HIV testing interventions, a discrete choice experiment (DCE) with six policy-relevant attributes of HIV testing options elicited the testing preferences of 300 female barworkers and 440 male Kilimanjaro mountain porters in northern Tanzania. Surveys were administered between September 2017 and July 2018. Participants were asked to complete 12 choice tasks, each involving first- and second-best choices from 3 testing options. DCE responses were analyzed using a random effects latent class logit (RELCL) model, in which the latent classes summarize common participant preference profiles, and the random effects capture additional individual-level preference heterogeneity with respect to three attribute domains: (a) privacy and confidentiality (testing venue, pre-test counseling, partner notification); (b) invasiveness and perceived accuracy (method for obtaining the sample for the HIV test); and (c) accessibility and value (testing availability, additional services provided). The Bayesian Information Criterion indicated the best model fit for a model with 8 preference classes, with class sizes ranging from 6% to 19% of participants. Substantial preference heterogeneity was observed, both between and within latent classes, with 12 of 16 attribute levels having positive and negative coefficients across classes, and all three random effects contributing significantly to participants' choices. The findings may help identify combinations of testing options that match the distribution of HIV testing preferences among high-risk populations; the methods may be used to systematically design heterogeneity-focused interventions using stated preference methods.

The Shinyanga Patient: A Patient's Journey through HIV Treatment Cascade in Rural Tanzania

The 2016-2017 Tanzania HIV Impact Survey (THIS) reported the accomplishments towards the 90-90-90 global HIV targets at 61-94-87, affirming the need to focus on the first 90 (i.e., getting 90% of people living with HIV (PLHIV) tested). We conducted a patient-pathway analysis to understand the gap observed, by assessing the alignment between where PLHIV seek healthcare and where HIV services are available in the Shinyanga region, Tanzania. We used existing and publicly available data from the National AIDS Control program, national surveys, registries, and relevant national reports. Region-wide, the majority (n = 458/722, 64%) of THIS respondents accessed their last HIV test at public sector facilities. There were 65.9%, 45.1%, and 74.1% who could also access antiretroviral therapy (ART), CD4 testing, and HIV viral load testing at the location of their last HIV test, respectively. In 2019, the viral suppression rate estimated among PLHIV on ART in the Shinyanga region was 91.5%. PLHIV access HIV testing mostly in public health facilities; our research shows that synergies can be achieved to improve access to services further down the cascade in this sector. Furthermore, effective engagement with the private sector (not-for-profit and for-profit) will help to achieve the last mile toward ending the HIV epidemic.

Designing HIV Testing and Self-Testing Services for Young People in Nigeria: A Discrete Choice Experiment

BACKGROUND AND OBJECTIVE

A third of new human immunodeficiency virus (HIV) infections occur among young people and the majority of young people living with HIV are in sub-Saharan Africa. We examined the strength of Nigerian youth preferences related to HIV testing and HIV self-testing (HIVST).

METHODS

Discrete choice experiments were conducted among Nigerian youth (age 14-24 years). Participants completed one of two discrete choice experiments: (1) preferred qualities of HIV testing (cost, location of test, type of test, person who conducts the test, and availability of HIV medicine at the testing site) and (2) preferred qualities of HIVST kits (cost, test quality, type of test, extra items, and support if tested positive). A random parameter logit model measured the strength of preferences.

RESULTS

A total of 504 youth participated: mean age 21 years (standard deviation 2 years), 38% male, and 35% had a higher than secondary school education. There was a strong preference overall to test given the scenarios presented, although male individuals were less likely to test for HIV or use HIVST kits. Youth preferred HIV testing services (with attributes in order of importance) that are free, blood-based testing, available in private/public hospitals or home, for HIV medications to be available in the same location as testing, and a doctor conducts the test. Participants preferred HIVST kits (with attributes in order of importance) that are available from community health centers, free, approved by the World Health Organization, include other sexually transmitted infection testing, have the option of an online chat, and oral-based HIVST.

CONCLUSIONS

The HIV home testing was equally preferred to testing in a hospital, suggesting a viable market for HIVST if kits account for youth preferences. Male youth were less likely to choose to test for HIV or use HIVST kits, underscoring the need for further efforts to encourage HIV testing among young male individuals.

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.

Preferences for family planning education among men and women in rural, highly religious Tanzanian communities: a discrete choice experiment

Unmet need for family planning (FP) remains prevalent worldwide. In Tanzania, 21.7% of women desire to delay pregnancy, but do not use modern contraception despite its free availability at local clinics. Our prior data suggest that this is related to complex gender and religious dynamics in rural communities. To understand how education about FP could be improved, we developed a discrete choice experiment (DCE) to rank preferences of six attributes of FP education. Results were stratified by gender. Sixty-eight women and 76 men completed interview-assisted DCEs. Participants significantly preferred education by a clinician (men = 0.62, p < .001; women = 0.38, p < .001) and education in mixed-gender groups (men = 0.55, p < .001; women = 0.26, p < .001). Women also significantly preferred education by a religious leader (0.26, p = .012), in a clinic versus church, mosque, or community centre (0.31, p = .002), and by a female educator (0.12, p = .019). Men significantly preferred a male educator (0.17, p = .015), whom they had never met (0.25, p < .001), and educating married and unmarried people separately (0.22, p = .002). Qualitative data indicate women who had not previously used contraception preferred education led by a religious leader in a church or mosque. FP education tailored to these preferences may reach a broader audience, dispel misconceptions about FP and ultimately decrease unmet need.

Heterogeneity in individual preferences for HIV testing: A systematic literature review of discrete choice experiments

BACKGROUND

Understanding variations in HIV testing preferences can help inform optimal combinations of testing services to maximize coverage. We conducted a systematic review of Discrete Choice Experiments (DCEs) eliciting HIV testing preference.

METHODS

We searched the published literature for papers that conducted DCEs to assess user preferences for HIV testing.

FINDINGS

We identified 237 publications; 14 studies conducted in 10 countries met inclusion criteria. Overall, test cost was one of the strongest drivers of preference, with participants preferring free or very low-cost testing. Confidentiality was a salient concern, particularly among key populations and persons who never tested. Participants in resource-limited settings preferred short travel distance and integration of HIV testing with other services. There was substantial heterogeneity across participant characteristics. For example, while women preferred home testing, high-risk groups (e.g. male porters, female bar workers) and men who had not tested in the last year preferred traveling a short distance for testing. HIV self-testing (HIVST) had high acceptability, particularly among those who had never HIV tested, although most users preferred blood-based sample collection over oral swabs. Participants highly valued post-test counselling availability after HIVST.

INTERPRETATION

Overall, participants value low-cost, confidential testing with short travel distance. HIVST is a promising strategy to increase testing coverage but post-test counseling and support should be made available. Educational campaigns to increase familiarity and build confidence in results of oral testing can improve the success of HIVST. DCEs conducted within clinic settings likely have limited generalizability to those not seeking care, particularly for key populations.

Using discrete choice experiments to design interventions for heterogeneous preferences: protocol for a pragmatic randomised controlled trial of a preference-informed, heterogeneity-focused, HIV testing offer for high-risk populations

INTRODUCTION

Approximately one million undiagnosed persons living with HIV in Southern and Eastern Africa need to test for HIV. Novel approaches are necessary to identify HIV testing options that match the heterogeneous testing preferences of high-risk populations. This pragmatic randomised controlled trial (PRCT) will evaluate the efficacy of a preference-informed, heterogeneity-focused HIV counselling and testing (HCT) offer, for improving rates of HIV testing in two high-risk populations.

METHODS AND ANALYSIS

The study will be conducted in Moshi, Tanzania. The PRCT will randomise 600 female barworkers and 600 male Kilimanjaro mountain porters across three study arms. All participants will receive an HIV testing offer comprised of four preference-informed testing options, including one 'common' option-comprising features that are commonly available in the area and, on average, most preferred among study participants-and three options that are specific to the study arm. Options will be identified using mixed logit and latent class analyses of data from a discrete choice experiment (DCE). Participants in Arm 1 will be offered the common option and three 'targeted' options that are predicted to be more preferred than the common option and combine features widely available in the study area. Participants in Arm 2 will be offered the common option and three 'enhanced' options, which also include HCT features that are not yet widely available in the study area. Participants in Arm 3, an active control arm, will be offered the common option and three predicted 'less preferred' options. The primary outcome will be uptake of HIV testing.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Duke University Health System IRB, the University of South Carolina IRB, the Ethics Review Committee at Kilimanjaro Christian Medical University College, Tanzania's National Institute for Medical Research, and the Tanzania Food & Drugs Authority (now Tanzania Medicines & Medical Devices Authority). Findings will be published in peer-reviewed journals. The use of rigorous DCE methods for the preference-based design and tailoring of interventions could lead to novel policy options and implementation science approaches.

TRIAL REGISTRATION NUMBER

NCT02714140.

The Preferred Qualities of Human Immunodeficiency Virus Testing and Self-Testing Among Men Who Have Sex With Men: A Discrete Choice Experiment

OBJECTIVES

Human immunodeficiency virus self-testing (HIVST) is a promising approach to improve HIV testing coverage. We aimed to understand HIV testing preferences of men who have sex with men (MSM) to optimize HIVST implementation.

METHODS

Discrete choice experiments (DCEs) were conducted among HIV-negative MSM living in Australia and aged ≥18 years. Men completed 1 of 2 DCEs: DCETest for preferred qualities of HIV testing (price, speed, window period, test type, and collector of specimen) and DCEKits for preferred qualities of HIVST kits (price, location of access, packaging, and usage instructions). Latent class conditional logit regression was used to explore similarities (or "classes") in preference behavior.

RESULTS

Overall, the study recruited 1606 men: 62% born in Australia, who had an average age of 36.0 years (SD 11.7), and a self-reported median of 4 (interquartile range 2-8) sexual partners in the last 6 months. The respondents to DCETest was described by 4 classes: "prefer shorter window period" (36%), "prefer self-testing" (27%), "prefer highly accurate tests" (22%), and "prefer low prices" (15%). Respondents to DCEKits were described by 4 classes: "prefer low prices" (48%), "prefer retail access (from pharmacy or online stores)" (29%), "prefer access at sex venues" (15%), and "prefer to buy from healthcare staff" (12%). Preferences varied by when someone migrated to Australia, age, frequency of testing, and number of sexual partners.

CONCLUSION

A subset of MSM, particularly infrequent testers, value access to HIVST. Expanding access to HIVST kits through online portals and pharmacies and at sex venues should be considered.

Heterogeneous Patient Preferences for Modern Antiretroviral Therapy: Results of a Discrete Choice Experiment

OBJECTIVE

Limited data describe patient preferences for the growing number of antiretroviral therapies (ARTs). We quantified preferences for key characteristics of modern ART deemed relevant to shared decision making.

METHODS

A discrete choice experiment survey elicited preferences for ART characteristics, including dosing (frequency and number of pills), administration characteristics (pill size and meal requirement), most bothersome side effect (from diarrhea, sleep disturbance, headaches, dizziness/difficulty thinking, depression, or jaundice), and most bothersome long-term effect (from increased risk of heart attacks, bone fractures, renal dysfunction, hypercholesterolemia, or hyperglycemia). Between March and August 2017, the discrete choice experiment was fielded to 403 treatment-experienced persons living with human immunodeficiency virus (HIV), enrolled from 2 infectious diseases clinics in the southern United States and a national online panel. Participants completed 16 choice tasks, each comparing 3 treatment options. Preferences were analyzed using mixed and latent class logit models.

RESULTS

Most participants were male (68%) and older (interquartile range: 42-58 years), and had substantial treatment experience (interquartile range: 7-21 years). In mixed logit analyses, all attributes were associated with preferences. Side and long-term effects were most important, with evidence of substantial preference heterogeneity. Latent class analysis identified 5 preference classes. For classes 1 (40%), 2 (24%), and 3 (21%), side effects were most important, followed by long-term effects. For class 4 (10%), dosing was most important. Class 5 (4%) was largely indifferent to ART characteristics.

CONCLUSION

Overall, treatment-experienced persons living with HIV valued minimizing side effects and long-term toxicities over dosing and administration characteristics. Preferences varied widely, highlighting the need to elicit individual patient preferences in models of shared antiretroviral decision making.

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

BACKGROUND AND OBJECTIVES

HIV testing is essential to access HIV treatment and care and plays a critical role in preventing transmission. Despite this, testing coverage is low among men in sub-Saharan Africa. Community-based testing has demonstrated potential to expand male testing coverage, yet scant evidence reveals how community-based services can be designed to optimize testing uptake. We conducted a discrete choice experiment (DCE) to elicit preferences and predict uptake of community-based testing by men in Uganda.

METHODS

Hypothetical choices between alternative community-based testing services and the option to opt-out of testing were presented to a random, population-based sample of 203 adult male residents. The testing alternatives varied by service delivery model (community health campaign, counselor-administered home-based testing, distribution of HIV self-test kits at local pharmacies), availability of multi-disease testing, access to antiretroviral therapy (ART), and provision of a US$0.85 incentive. We estimated preferences using a random parameters logit model and explored whether preferences varied by participant characteristics through subgroup analyses. We simulated uptake when a single and when two community-based testing services are made available, using reference values of observed uptake to calibrate predictions.

RESULTS

The share of the adult male population predicted to test for HIV ranged from 0.15 to 0.91 when a single community-based testing service is made available and from 0.50 to 0.96 when two community-based services are provided concurrently. ART access was the strongest driver of choices (relative importance [RI] = 3.01, 95% confidence interval [CI]: 1.74-4.29), followed by the service delivery model (RI = 1.27, 95% CI 0.72-1.82) and availability of multi-disease testing (RI = 1.27, 95% CI 0.09-2.45). A US$0.85 incentive had the least yet still significant influence on choices (RI = 0.77, 95% CI 0.06-1.49). Men who perceived their risk of having HIV to be relatively elevated had higher predicted uptake of HIV self-test kits at local pharmacies, as did young adult men compared to men aged ≥ 30 years. Men who earned ≤ the daily median income had higher predicted uptake of all community-based testing services versus men who earned above the daily median income.

CONCLUSION

Substantial opportunity exists to optimize the delivery of HIV testing to expand uptake by men; using an innovative DCE, we deliver timely, actionable guidance for promoting community-based testing by men in Uganda. We advance the stated preference literature methodologically by describing how we constructed and evaluated a pragmatic experimental design, used interaction terms to conduct subgroup analyses, and harnessed participant-specific preference estimates to predict and calibrate testing uptake.

Socio-demographic characteristics and risk factors for HIV transmission in female bar workers in sub-Saharan Africa: a systematic literature review

Background

Although sex workers are considered a key population in the HIV epidemic in sub-Saharan Africa (SSA), less consideration has been given to female bar workers (FBW), whose primary occupation is not sex work but who often engage in transactional sex. Understanding FBWs’ risk profiles is central to designing targeted HIV prevention interventions for them. This systematic review describes the socio-demographic characteristics and risk factors for HIV transmission among FBWs in SSA.

Methods

We searched six databases: PubMed, Google Scholar, Web of Science, Popline, Embase and additionally the World Health Organization’s WHOLIS database for grey literature between July and September 2017. Inclusion criteria were reporting (1) primary socio-demographic or behavioral data; on (2) women who sold or delivered drinks to clients; (3) in establishments serving alcohol; (4) in SSA. We excluded studies not presenting separate data on FBWs. We extracted quantitative and qualitative data from the selected studies and conducted a qualitative synthesis of findings.

Results

We found 4565 potentially eligible articles, including duplicates. After applying inclusion and exclusion criteria, we retained 19 articles. FBWs often migrated from rural to urban areas due to economic need or social marginalization. They began bar-based transactional sex due to low wages, peer pressure and to increase financial independence. FBWs had high HIV risk awareness but low agency to negotiate condom use, particularly with regular partners or when offered higher prices for condomless sex. FBWs were also vulnerable to violence and stigmatization.

Conclusions

FBWs are a vulnerable population for HIV infection. Despite social stigmatization and elevated risk of contracting STIs, bar work remains attractive because it enables unskilled women to both, make a living and maintain some independence. FBWs face HIV-related risk factors at the individual, community and societal level and may benefit from biomedical, behavioral and structural interventions.

Feasibility of an HIV self-testing intervention: a formative qualitative study among individuals, community leaders, and HIV testing experts in northern Tanzania

BACKGROUND

Achieving the 95-95-95 global targets by 2030, innovative HIV testing models, such as HIV self-testing are needed for people, who are unaware of their HIV status. We aimed to explore key informants, mountain climbing porters, and female bar workers' attitudes, perceived norms, and personal agency related to HIV self-testing.

METHODS

This was a formative qualitative study to inform the design of an HIV self-testing intervention in Northern Tanzania. Informed by the Integrated Behaviour Model, we conducted four focus group discussions, and 18 in-depth interviews with purposively selected participants. Data were analyzed using the framework method.

RESULTS

We recruited 55 participants. Most participants had positive attitudes towards HIVST, in that they anticipated positive consequences related to the introduction and uptake of HIVST. These included privacy and convenience, avoidance of long queues at health facilities, reduced counselor workload, and reduced indirect costs (given that transport to health facilities might not be required). Participants expressed the belief that significant people in their social environment, such as parents and peers, would approve their uptake of HIVST, and that they would accept HIVST. Additionally, features of HIVST that might facilitate its uptake were that it could be performed in private and would obviate visits to health facilities. Most participants were confident in their capacity to use HIVST kits, while a few were less confident about self-testing while alone. Strategies to maximize beliefs about personal agency and facilitate uptake included supplying the self-test kits in a way that was easy to access, and advocacy. Perceived potential constraints to the uptake of HIVST were the cost of buying the self-test kits, poverty, illiteracy, poor eyesight, fear of knowing one's HIV status, lack of policy/ guidelines for HIVST, and the absence of strategies for linkage to HIV care, treatment, and support.

CONCLUSIONS

The findings suggest that HIVST may be feasible to implement in this study setting, with the majority of participants reporting positive attitudes, supportive perceived norms, and self-efficacy. Hence, future HIVST interventions should address the negative beliefs, and perceived barriers towards HIVST to increase HIV testing among the target population in Northern Tanzania.

Stated-preference research in HIV: A scoping review

Discrete choice experiments (DCE), conjoint analysis (CA), and best-worst scaling (BWS) are quantitative techniques for estimating consumer preferences for products or services. These methods are increasingly used in healthcare research, but their applications within the field of HIV research have not yet been described. The objective of this scoping review was to systematically map the extent and nature of published DCE, CA, and BWS studies in the field of HIV and identify priority areas where these methods can be used in the future. Online databases were searched to identify published HIV-related DCE, CA and BWS studies in any country and year as the primary outcome. After screening 1,496 citations, 57 studies were identified that were conducted in 26 countries from 2000-2017. The frequency of published studies increased over time and covered HIV themes relating to prevention (n = 25), counselling and testing (n = 10), service delivery (n = 10), and antiretroviral therapy (n = 12). Most studies were DCEs (63%) followed by CA (37%) and BWS (4%). The median [IQR] sample size was 288 [138-496] participants, and 74% of studies used primary qualitative data to develop attributes. Only 30% of studies were conducted in sub-Saharan Africa where the burden of HIV is highest. Moreover, few studies surveyed key populations including men who have sex with men, transgender people, pregnant and postpartum women, adolescents, and people who inject drugs. These populations represent priorities for future stated-preference research. This scoping review can help researchers, policy makers, program implementers, and health economists to better understand the various applications of stated-preference research methods in the field of HIV.

Structural, interpersonal, psychosocial, and behavioral risk factors for HIV acquisition among female bar workers in Dar es Salaam, Tanzania

In sub-Saharan Africa, female bar workers (FBWs) often serve as informal sex workers. Little is known about the prevalence of HIV and HIV-related risk factors among FBWs in Dar es Salaam (DSM), Tanzania. Using an adapted Structural HIV Determinants Framework, we identified structural, interpersonal, psychosocial, and behavioral risk factors for HIV acquisition. We compared the prevalence of HIV and HIV-related risk factors among a random sample of 66 FBWs from DSM to an age-standardized, representative sample of female DSM-residents from the 2016 Demographic and Health and 2011-2012 AIDS Indicator Surveys. Compared to other women in DSM, FBWs had elevated prevalence of all four groups of risk factors. Key risk factors included gender and economic inequalities (structural); sexual violence and challenges negotiating condom use (interpersonal); depression, post-traumatic stress disorder, and low social support (psychosocial); and history of unprotected sex, multiple sex partners, and high alcohol consumption (behavioral). HIV prevalence did not differ between FBWs (7.1%, 95% CI 3.7-13.3%) and survey respondents (7.7%, 95% CI: 5.3-11.1%), perhaps due to FBWs' higher - though sub-optimal - engagement with HIV prevention strategies. Elevated exposure to HIV-related risk factors but low HIV prevalence suggests economic, psychosocial, and biomedical interventions may prevent HIV among FBWs in DSM.

Preferences for HIV testing services among men who have sex with men in the UK: A discrete choice experiment

BACKGROUND

In the UK, approximately 4,200 men who have sex with men (MSM) are living with HIV but remain undiagnosed. Maximising the number of high-risk people testing for HIV is key to ensuring prompt treatment and preventing onward infection. This study assessed how different HIV test characteristics affect the choice of testing option, including remote testing (HIV self-testing or HIV self-sampling), in the UK, a country with universal access to healthcare.

METHODS AND FINDINGS

Between 3 April and 11 May 2017, a cross-sectional online-questionnaire-based discrete choice experiment (DCE) was conducted in which respondents who expressed an interest in online material used by MSM were asked to imagine that they were at risk of HIV infection and to choose between different hypothetical HIV testing options, including the option not to test. A variety of different testing options with different defining characteristics were described so that the independent preference for each characteristic could be valued. The characteristics included where each test is taken, the sampling method, how the test is obtained, whether infections other than HIV are tested for, test accuracy, the cost of the test, the infection window period, and how long it takes to receive the test result. Participants were recruited and completed the instrument online, in order to include those not currently engaged with healthcare services. The main analysis was conducted using a latent class model (LCM), with results displayed as odds ratios (ORs) and probabilities. The ORs indicate the strength of preference for one characteristic relative to another (base) characteristic. In total, 620 respondents answered the DCE questions. Most respondents reported that they were white (93%) and were either gay or bisexual (99%). The LCM showed that there were 2 classes within the respondent sample that appeared to have different preferences for the testing options. The first group, which was likely to contain 86% of respondents, had a strong preference for face-to-face tests by healthcare professionals (HCPs) compared to remote testing (OR 6.4; 95% CI 5.6, 7.4) and viewed not testing as less preferable than remote testing (OR 0.10; 95% CI 0.09, 0.11). In the second group, which was likely to include 14% of participants, not testing was viewed as less desirable than remote testing (OR 0.56; 95% CI 0.53, 0.59) as were tests by HCPs compared to remote testing (OR 0.23; 95% CI 0.15, 0.36). In both classes, free remote tests instead of each test costing £30 was the test characteristic with the largest impact on the choice of testing option. Participants in the second group were more likely to have never previously tested and to be non-white than participants in the first group. The main study limitations were that the sample was recruited solely via social media, the study advert was viewed only by people expressing an interest in online material used by MSM, and the choices in the experiment were hypothetical rather than observed in the real world.

CONCLUSIONS

Our results suggest that preferences in the context we examined are broadly dichotomous. One group, containing the majority of MSM, appears comfortable testing for HIV but prefers face-to-face testing by HCPs rather than remote testing. The other group is much smaller, but contains MSM who are more likely to be at high infection risk. For these people, the availability of remote testing has the potential to significantly increase net testing rates, particularly if provided for free.

No Place Like Home? Disentangling Preferences for HIV Testing Locations and Services Among Men Who Have Sex with Men in China

In China, some health departments and gay community-based organizations have begun to offer home-based HIV testing kits in order to augment test uptake among men who have sex with men (MSM). However, HIV test preferences and motivations for home-testing among MSM in China are not well understood. The HIV testing preferences of 803 MSM throughout China were evaluated using single-item assessment and a discrete choice experiment (DCE). In both the single-item assessment and DCE, participants expressed strong preference for free and anonymous testing by health professionals. Both approaches also indicated that naïve testers most prefer home testing. However, among previous testers, the single-item assessment indicated that "home" was the most preferred testing location (vs. hospital or clinic), while the DCE indicated that "home" was the least preferred testing location after controlling for anonymity. HIV home-testing may have limited appeal to previously tested Chinese MSM if anonymity is not maintained.

Accounting for Scale Heterogeneity in Healthcare-Related Discrete Choice Experiments when Comparing Stated Preferences: A Systematic Review

BACKGROUND

Scale heterogeneity, or differences in the error variance of choices, may account for a significant amount of the observed variation in the results of discrete choice experiments (DCEs) when comparing preferences between different groups of respondents.

OBJECTIVE

The aim of this study was to identify if, and how, scale heterogeneity has been addressed in healthcare DCEs that compare the preferences of different groups.

METHODS

A systematic review identified all healthcare DCEs published between 1990 and February 2016. The full-text of each DCE was then screened to identify studies that compared preferences using data generated from multiple groups. Data were extracted and tabulated on year of publication, samples compared, tests for scale heterogeneity, and analytical methods to account for scale heterogeneity. Narrative analysis was used to describe if, and how, scale heterogeneity was accounted for when preferences were compared.

RESULTS

A total of 626 healthcare DCEs were identified. Of these 199 (32%) aimed to compare the preferences of different groups specified at the design stage, while 79 (13%) compared the preferences of groups identified at the analysis stage. Of the 278 included papers, 49 (18%) discussed potential scale issues, 18 (7%) used a formal method of analysis to account for scale between groups, and 2 (1%) accounted for scale differences between preference groups at the analysis stage. Scale heterogeneity was present in 65% (n = 13) of studies that tested for it. Analytical methods to test for scale heterogeneity included coefficient plots (n = 5, 2%), heteroscedastic conditional logit models (n = 6, 2%), Swait and Louviere tests (n = 4, 1%), generalised multinomial logit models (n = 5, 2%), and scale-adjusted latent class analysis (n = 2, 1%).

CONCLUSIONS

Scale heterogeneity is a prevalent issue in healthcare DCEs. Despite this, few published DCEs have discussed such issues, and fewer still have used formal methods to identify and account for the impact of scale heterogeneity. The use of formal methods to test for scale heterogeneity should be used, otherwise the results of DCEs potentially risk producing biased and potentially misleading conclusions regarding preferences for aspects of healthcare.

Discrete Choice Experiments in Health Economics: Past, Present and Future

OBJECTIVES

Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges.

METHODS

A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated.

RESULTS

Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels.

CONCLUSIONS

The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.

A discrete choice experiment to investigate patient preferences for HIV testing programs in Bogotá, Colombia

BACKGROUND

To assess patients' preferences for HIV testing in Colombia.

METHODS

A discrete choice experiment was used to assess preferences of patients diagnosed with HIV, for HIV testing in two HIV clinics in Bogotá, Colombia. Patients were asked to choose repeatedly between two hypothetical HIV testing options that varied with respect to five attributes: distance to testing site, confidentiality, testing days, sample collection method, and the services if HIV positive. A random parameter model was used to analyze the data.

RESULTS

A total of 249 questionnaires were eligible for data analysis. Respondents showed a preference for testing on weekdays, nobody being aware, a sample taken from the arm, and receiving medications through a referral. The respondents showed a high negative preference for many people being aware, followed by testing during the weekend and home testing. Subgroup analyses by gender and prior testing history did not reveal significant differences.

CONCLUSION

This study suggests that patients' preferences for HIV testing focused especially on confidentiality, availability during weekdays, and using a sample from the arm. This information could be useful to improve uptake of HIV testing in Bogotá, Colombia.

Preferences for linkage to HIV care services following a reactive self-test: discrete choice experiments in Malawi and Zambia

OBJECTIVES

The current research identifies key drivers of demand for linkage into care following a reactive HIV self-test result in Malawi and Zambia. Preferences are explored among the general population and key groups such as HIV-positive individuals and adolescents.

DESIGN

We used discrete choice experiments (DCEs) embedded in representative household surveys to quantify the relative strength of preferences for various HIV services characteristics.

METHODS

The DCE was designed on the basis of a literature review and qualitative studies. Data were collected within a survey (Malawi n = 553, Zambia n = 388), pooled across country and analysed using mixed logit models. Preference heterogeneity was explored by country, age, sex, wealth, HIV status and belief that HIV treatment is effective.

RESULTS

DCE results were largely consistent across countries. Major barriers for linkage were fee-based testing and long wait for testing. Community-based confirmatory testing, that is at the participant's or counsellor's home, was preferred to facility-based confirmation. Providing separated waiting areas for HIV services at health facilities and mobile clinics was positively viewed in Malawi but not in Zambia. Active support for linkage was less important to respondents than other attributes. Preference heterogeneity was identified: overall, adolescents were more willing to seek care than adults, whereas HIV-positive participants were more likely to link at health facilities with separate HIV services.

CONCLUSION

Populations in Malawi and in Zambia were responsive to low-cost, HIV care services with short waiting time provided either at the community or privately at health facilities. Hard-to-reach groups could be encouraged to link to care with targeted support.

Applying stated-preference methods to improve health systems in sub-Saharan Africa: a systematic review

INTRODUCTION

Sub-Saharan African health systems must balance shifting disease burdens with desires for robust institutions. Stated-preference methods have been applied extensively to elicit health care workers' preferences and priorities for rural practice. This systematic review characterizes the range of their applications to African health systems problems. Areas covered: A PRISMA protocol was submitted to PROSPERO. Six databases were queried for peer-reviewed articles using quantitative stated-preference methods to evaluate a health systems-related trade-off. Quality was assessed using the PREFS checklist. Seventy-seven articles published between 1996 and 2017 met review criteria. Methods were primarily choice-based: discrete-choice experiments (n = 46), ranking/allocation techniques (n = 21), conjoint analyses (n = 7), and best-worst scaling (n = 3). Trade-offs fell into six 'building blocks': service features (n = 27), workforce incentives (n = 17), product features (n = 14), system priorities (n = 14), insurance features (n = 4), and research priorities (n = 1). Five countries dominated: South Africa (n = 11), Ghana (n = 9), Malawi (n = 9), Uganda (n = 9), and Tanzania (n = 8). Discrete-choice experiments were of highest quality (mean score: 3.36/5). Expert commentary: Stated-preference methods have been applied to many health systems contexts throughout sub-Saharan Africa. Studies examined established strategic areas, especially primary health care for women, prevention and treatment of infectious diseases, and workforce development. Studies have neglected the emerging areas of non-communicable diseases.

Would you test for 5000 Shillings? HIV risk and willingness to accept HIV testing in Tanzania

OBJECTIVES

Despite substantial public health efforts to increase HIV testing, testing rates have plateaued in many countries and rates of repeat testing for those with ongoing risk are low. To inform policies aimed at increasing uptake of HIV testing, we identified characteristics associated with individuals' willingness-to-accept (WTA) an HIV test in a general population sample and among two high-risk populations in Moshi, Tanzania.

METHODS

In total, 721 individuals, including randomly selected community members (N = 402), female barworkers (N = 135), and male Kilimanjaro mountain porters (N = 184), were asked in a double-bounded contingent valuation format if they would test for HIV in exchange for 2000, 5000 or 10,000 Shillings (approximately $1.30, $3.20, and $6.40, respectively). The study was conducted between September 2012 and February 2013.

RESULTS

More than one quarter of participants (196; 27 %) stated they would be willing to test for Tanzania Shilling (TSH) 2000, whereas one in seven (98; 13.6 %) required more than TSH 10,000. The average WTA estimate was TSH 4564 (95 % Confidence Interval: TSH 4201 to 4927). Significant variation in WTA estimates by gender, HIV risk factors and other characteristics plausibly reflects variation in individuals' valuations of benefits of and barriers to testing. WTA estimates were higher among males than females. Among males, WTA was nearly one-third lower for those who reported symptoms of HIV than those who did not. Among females, WTA estimates varied with respondents' education, own and partners' HIV testing history, and lifetime reports of transactional sex. For both genders, the most significant association was observed with respondents' perception of the accuracy of the HIV test; those believing HIV tests to be completely accurate were willing to test for approximately one third less than their counterparts. The mean WTA estimates identified in this study suggest that within the study population, incentivized universal HIV testing could potentially identify undiagnosed HIV infections at an incentive cost of $150 per prevalent infection and $1400 per incident infection, with corresponding costs per quality adjusted life year (QALY) gained of $70 for prevalent and $620 for incident HIV infections.

CONCLUSIONS

The results support the value of information about the accuracy of HIV testing, and suggest that relatively modest amounts of money may be sufficient to incentivize at-risk populations to test.