Preferences of people living with HIV for differentiated care models in Kenya: A discrete choice experiment

Experiences and Preferences in Zambia and South Africa for Delivery of HIV Treatment During a Client's First Six Months: Results of the PREFER Study's Cross-Sectional Baseline Survey

Disengagement from antiretroviral therapy (ART) is highest in the early treatment period (≤ 6 months after initiation/re-initiation), but low intensity models designed to increase retention generally exclude these clients. We describe client preferences for HIV service delivery in the early treatment period. From 9/2022 to 6/2023, we surveyed adult clients who were initiating or on ART for ≤ 6 months at primary health facilities in South Africa and Zambia. We collected data on experiences with and preferences for HIV treatment. We enrolled 1,098 participants in South Africa (72% female, median age 33) and 771 in Zambia (67% female, median age 32), 38% and 34% of whom were initiating/re-initiating ART in each country, respectively. While clients expressed varied preferences, most participants (94% in South Africa, 87% in Zambia) were not offered choices regarding service delivery. 82% of participants in South Africa and 36% in Zambia reported receiving a 1-month supply of medication at their most recent visit; however, South African participants preferred 2- or 3-month dispensing (69%), while Zambian participants preferred 3-or 6-month dispensing (85%). Many South African participants (65%) would prefer to collect medication in community settings, while Zambian participants (70%) preferred clinic-based collection. Half of participants desired more one-on-one counselling and health information. Most participants reported positive experiences with providers, but long waiting queues were reported by South African participants.During the first six months on ART, many clients would prefer less frequent clinic visits, longer dispensing intervals, and frequent, high-quality counselling. Care models for the early treatment period should reflect these preferences.Registration: Clinicaltrials.gov NCT05454839, Clinicaltrials.gov NCT05454852.

Impact of Differentiated Service Delivery Models on Quality of Life among People living with HIV in Uganda - A Quasi-Experimental Study

Background

Differentiated service delivery (DSD) models in resource-limited settings have reduced strain on health services and improved client experience, retention and viral suppression, but little is known about the impact of HIV DSD models on quality of life (QoL), which is essential for optimizing person-centered care. This study assessed the impact of DSD models on QoL, loss to follow-up (LTFU), and mortality among persons living with HIV (PLHIV) on ART over time at a large urban HIV clinic in Uganda.

Methods

We analyzed records of 1,000 PLHIV who had been on ART for 10 years and followed up for eight years, starting in 2014 or 2015 at the Infectious Diseases Institute clinic in Kampala, Uganda. The primary outcome, QoL, was assessed using an adapted Medical Outcomes Study (MOS-HIV) tool. Secondary outcomes included sustained viral suppression (< 200 copies/mL), all-cause mortality, and loss to follow-up or LTFU (missing clinic visits for ≥ 3 months). Outcomes were compared across three DSD models-fast-track drug refill (FTDR), facility-based groups (FBG), and a composite model combining FTDR and FBG against the facility-based individual management (FBIM), the standard of care (SOC). Inverse probability treatment weighting was used to achieve comparability in measured covariates across the DSD models followed by mixed effects modeling. Robustness of results was checked using G-computation analysis.

Results

Of 1,000 records for PLHIV, 980 were analyzed. 62% were female and 95% virally suppressed at baseline. After eight years of follow-up, participants on DSD models had higher QoL (90.4% vs 89.1%; weighted mean ratio 3.66, 95% CI 2.10-6.37, p-value < 0.001), better sustained viral suppression, lower mortality, and reduced LTFU rates compared to SOC.

Conclusion

These findings support the broader adoption of DSD models in delivering ART across HIV programs to enhance the QoL and clinical outcomes among PLHIV.

Long-term retention and positive deviant practices in Uganda's community client-led antiretroviral distribution groups (CCLADs): a mixed-methods study

BACKGROUND

HIV testing and starting antiretroviral therapy (ART) are pivotal in treating people living with HIV (PLHIV) but sustaining PLHIV on treatment remains challenging. We assessed retention and attrition in community client-led antiretroviral distribution groups (CCLADs) in Uganda and identified positive deviant practices that foster long-term retention.

METHODS

Using explanatory mixed methods, we collected longitudinal medical data from 65 health facilities across 12 districts in East Central Uganda. Quantitative phase, from 18 April 2021 to 30 May 2021, employed survival analysis and Cox regression to assess retention and identify attrition risk factors. Qualitative inquiry focused on four districts with high attrition from 11 August 2021 to 20 September 2021, where we identified nine health facilities exhibiting high retention in CCLADs. We purposively selected 50 clients for in-depth interviews (n=22) or focus group discussions (n=28). Using thematic analysis, we identified positive deviant practices. We integrated quantitative and qualitative findings into joint displays.

RESULTS

Involving 3055 PLHIV, the study showed retention rates of 97.5% at 6 months, declining to 89.7% at 96 months. Attrition risk factors were lower levels of care (health centre three (adjusted HR (aHR) 2.80, 95% CI 2.00 to 3.65) and health centre four (aHR 3.61, 95% CI 2.35 to 5.54)); being unemployed (aHR 2.21, 95% CI 1.00 to 4.84); enrolment year into CCLAD (aHR 23.93, 95% CI 4.66 to 123.05) and virological failure (aHR 3.41, 95% CI 2.51 to 4.63). Of 22 clients interviewed, 8 were positive deviants. Positive deviants were characterised by prolonged retention in CCLADs, improved clinical outcomes and practised uncommon behaviours that enabled them to find better solutions than their peers. Positive deviant practices included fostering family-like settings, offering financial or self-development advice, and promoting healthy lifestyles.

CONCLUSIONS

Findings underscore the importance of addressing factors contributing to attrition and leveraging positive deviant practices to optimise retention and long-term engagement in HIV care.

The elicitation of patient and physician preferences for calculating consumer-based composite measures on hospital report cards: results of two discrete choice experiments

PURPOSE

The calculation of aggregated composite measures is a widely used strategy to reduce the amount of data on hospital report cards. Therefore, this study aims to elicit and compare preferences of both patients as well as referring physicians regarding publicly available hospital quality information METHODS: Based on systematic literature reviews as well as qualitative analysis, two discrete choice experiments (DCEs) were applied to elicit patients' and referring physicians' preferences. The DCEs were conducted using a fractional factorial design. Statistical data analysis was performed using multinomial logit models RESULTS: Apart from five identical attributes, one specific attribute was identified for each study group, respectively. Overall, 322 patients (mean age 68.99) and 187 referring physicians (mean age 53.60) were included. Our models displayed significant coefficients for all attributes (p < 0.001 each). Among patients, "Postoperative complication rate" (20.6%; level range of 1.164) was rated highest, followed by "Mobility at hospital discharge" (19.9%; level range of 1.127), and ''The number of cases treated" (18.5%; level range of 1.045). In contrast, referring physicians valued most the ''One-year revision surgery rate'' (30.4%; level range of 1.989), followed by "The number of cases treated" (21.0%; level range of 1.372), and "Postoperative complication rate" (17.2%; level range of 1.123) CONCLUSION: We determined considerable differences between both study groups when calculating the relative value of publicly available hospital quality information. This may have an impact when calculating aggregated composite measures based on consumer-based weighting.

Patients' Preferences for Antiretroviral Therapy Service in Northwest Ethiopia: A Discrete Choice Experiment

Objective. We aim to evaluate patients' preferences for antiretroviral therapy (ART) to enhance shared decision making in clinical practice in Northwest Ethiopia. Methods. A discrete choice experiment approach was used among adult patients from 36 randomly selected public health facilities from February 6, 2023, to March 29, 2023. A literature review, qualitative work, ranking and rating surveys, and expert consultation were used to identify the attributes. Location, provider, frequency of visit, appointment modality, refill time, and cost of visit were the 6 ART service features chosen. Participants were given the option of choosing between 2 hypothetical differentiated ART delivery models. Mixed logit and latent class analysis were used. Results: Four hundred fifty-six patients completed the choice task. Respondents preferred to receive ART refills alone at health facilities by health care workers without having to have frequent visits and with reduced cost of visit. Overall, the participants valued the cost of the visit the most while they valued the timing of ART refill the least. Participants were willing to pay only for the attributes of frequency of visit and medication refill time. The latent class model with 3 classes provided the best model fit. Location, cost, and frequency were the most important attributes in class 1, class 2, and class 3, respectively. Income and marital status significantly predicted class membership. Conclusions. Respondents preferred to receive refills at health facilities, less frequent visits, individual appointments, service provision by health care workers, and reduced cost of visit. The cost attribute had the greatest impact on the choice of patients. Health care workers should consider the preferences of patients while providing ART services to meet patients' expectations and choices.

Highlights

A discrete choice experiment was used to elicit patient preferences.People living with HIV preferred receiving medication refills at health facilities, less frequent visits, individual appointments, service delivery by health care workers, and lower visit costs.Health care workers should consider the preferences of patients while providing ART service to meet their expectations and choices.Scaling up differentiated HIV treatment services is crucial for patient-centered care.

Preferences of Pregnant and Postpartum Women for Differentiated Service Delivery in Kenya

BACKGROUND

Differentiated service delivery models are implemented by HIV care programs globally, but models for pregnant and postpartum women living with HIV (PPWH) are lacking. We conducted a discrete choice experiment to determine women's preferences for differentiated service delivery.

SETTING

Five public health facilities in western Kenya.

METHODS

PPWH were enrolled from April to December 2022 and asked to choose between pairs of hypothetical clinics that differed across 5 attributes: clinic visit frequency during pregnancy (monthly vs. every 2 months), postpartum visit frequency (monthly vs. only with routine infant immunizations), seeing a mentor mother (each visit vs. as needed), seeing a clinician (each visit vs. as needed), and basic consultation cost (0, 50, or 100 Kenya Shillings [KSh]). We used multinomial logit modeling to determine the relative effects (β) of each attribute on clinic choice.

RESULTS

Among 250 PPWH (median age 31 years, 42% pregnant, 58% postpartum, 20% with a gap in care), preferences were for pregnancy visits every 2 months (β = 0.15), postpartum visits with infant immunizations (β = 0.36), seeing a mentor mother and clinician each visit (β = 0.05 and 0.08, respectively), and 0 KSh cost (β = 0.39). Preferences were similar when stratified by age, pregnancy, and retention status. At the same cost, predicted market choice for a clinic model with fewer pregnant/postpartum visits was 75% versus 25% for the standard of care (ie, monthly visits during pregnancy/postpartum).

CONCLUSION

PPWH prefer fewer clinic visits than currently provided within the standard of care in Kenya, supporting the need for implementation of differentiated service delivery for this population.

Clinical outcomes after extended 12-month antiretroviral therapy prescriptions in a community-based differentiated HIV service delivery programme in South Africa: a retrospective cohort study

INTRODUCTION

There is an urgent need for more efficient models of differentiated antiretroviral therapy (ART) delivery for people living with HIV (PLHIV), with the World Health Organization calling for evidence to guide whether annual ART prescriptions and consultations (12M scripts) should be recommended in global guidelines. We assessed the association between 12M scripts (allowed temporarily during the COVID-19 pandemic) versus standard 6-month prescriptions and consultations (6M scripts) and clinical outcomes.

METHODS

We performed a retrospective cohort study using routine, de-identified data from 59 public clinics in KwaZulu-Natal, South Africa. We included PLHIV aged ≥18 years with a recent suppressed viral load (VL) who had been referred for community ART delivery with 6M or 12M scripts. We used modified Poisson regression to compare 12-month retention-in-care (≤90 days late for all visits) and viral suppression (<50 copies/ml) between prescription groups.

RESULTS

Among 27,148 PLHIV referred for community ART during Jun-Dec 2020, 57.4% received 12M scripts. The median age was 39 years and 69.4% were women. Age, sex, prior community ART use and time on ART were similar across groups. However, more of the 12M script group had dolutegravir-based regimens (60.0% vs. 46.3%). The median (interquartile range) number of clinic visits in the year of follow-up was 1(1-1) in the 12M group and 2(2-3) in the 6M group. Retention was 94.6% (95% confidence interval [CI]: 94.2%-94.9%) among those receiving 12M scripts and 91.8% (95% CI: 91.3%-92.3%) among those with 6M scripts. 17.1% and 16.9% of clients in the 12M and 6M groups were missing follow-up VL data, respectively. Among those with VLs, 92.4% (95% CI: 92.0%-92.9%) in the 12M group and 91.4% (95% CI: 90.8%-92.0%) in the 6M group were suppressed. After adjusting for age, sex, ART regimen, time on ART, prior community ART use and calendar month, retention (adjusted risk ratio [aRR]: 1.03, 95% CI: 1.01-1.05) and suppression (aRR: 1.00, 95% CI: 0.99-1.01) were similar across groups.

CONCLUSIONS

Among PLHIV referred for community ART with a recent suppressed VL, the use of 12M scripts reduced clinic visits without impacting short-term clinical outcomes. 12M scripts should be considered for differentiated service delivery programmes.

Preferences of People Living with HIV for Long-Acting Antiretroviral Treatment in Germany: Evidence from a Discrete Choice Experiment

OBJECTIVE

This study aimed to elicit preferences for attributes of current and novel long-acting antiretroviral therapy for human immunodeficiency virus treatment.

METHODS

Primary survey data were collected (July-October 2022) on a sample of 333 people living with human immunodeficiency virus in Germany from a patient recruitment agency. Respondents were invited by e-mail to respond to a web-based questionnaire. After performing a systematic literature review, we conducted qualitative semi-structured interviews to identify and select the key attributes of drug therapy for patients' preferences for human immunodeficiency virus treatment. Based on this, a discrete choice experiment survey elicited preferences for long-acting antiretroviral therapy characteristics, including the type of medication, frequency of dosing, the location of treatment, the risk of both short-term and long-term side effects, as well as possible interactions with other medications or (party) drugs. A statistical data analysis was performed using multinomial logit models. An additional latent class multinomial logit was performed to evaluate subgroup differences.

RESULTS

Overall, 226 respondents (86% male, mean age 46.1 years) were included in the analysis. The frequency of dosing (36.1%) and the risk of long-term side effects (28.2%) had the greatest influence on preferences. The latent class analysis identified two patient groups. While the first class (n = 135; 87% male, mean age 44.4 years) found the frequency of dosing (44.1%) to be most important, the second class (n = 91; 85% male, mean age 48.6 years) focused on the risk of long-term side effects (50.3%). The evaluation of structural variables showed that male respondents, those living in small cities or villages, and those with better health status results were significantly more likely to be assigned to the second class (p < 0.05 each).

CONCLUSIONS

All attributes included in our survey were important to participants when choosing an antiretroviral therapy. We found evidence that the frequency of dosing as well as the risk of long-term side effects have a particular impact on the acceptance of novel therapy regimens and should be considered in order to optimize adherence and satisfaction.

Development of attributes and attribute levels for a discrete choice experiment on patients' and providers' choice for antiretroviral therapy service in Northwest Ethiopia

BACKGROUND

Discrete choice experiments (DCEs) are used to assess the strength of preferences and value of interventions. However, researchers using this approach have been criticized for not conducting or publishing rigorous studies to select the required attributes and levels. Proper specification of attributes and their levels determines the validity of DCE. Hence, our study aimed to identify and define attributes and levels for the design of a DCE to elicit patients' and providers' preferences for ART service in Northwest Ethiopia.

METHODS

Four stages were followed to derive the final list of attributes and levels: (1) a literature review to derive conceptual attributes; (2) key informant interviews of 17 providers and in-depth interviews of 15 adult stable patients to identify context-specific attributes and attribute levels; (3) ranking survey among 31 HIV/AIDS program implementers and rating survey among 35 adult stable patients and 42 health workers providing antiretroviral therapy (ART) service to indicate participants' preference of attributes; and (4) an expert opinion to reduce the list of attributes and levels.

RESULTS

First, a literature review identified 23 candidate attributes. Second, individual-level analysis of the qualitative transcripts confirmed 15 of these 23 attributes. Third, the ranking and rating surveys put the importance of the 23 ART service attributes in order of preference. Fourth, through discussions with eight experts, 17 attributes were discarded based on multiple criteria. The six retained attributes were: the location of ART refills, the frequency of receiving ART refills, the person providing ART refills, the participants/others seen at the same ART refill visit, medication refill pick-up/delivery times, and the total cost of the visit during antiretroviral (ARV) medication refill. Finally, levels were assigned to these 6 attributes based on data from the literature, transcripts, and knowledge of the Ethiopian context.

CONCLUSIONS

This detailed description illuminates the attribute development process and provides the reader with a basis for evaluating the rigor of this phase of DCE construction. This paper contributes empirical evidence to the limited methodological literature on attributes and levels of development for DCE, thereby providing further empirical guidance on ART service preference, specifically among patients of low- and middle-income countries.

HIV Care Preferences among Young People Living with HIV in Lesotho: A Secondary Data Analysis of the PEBRA Cluster Randomized Trial

Introduction

Sub-Saharan Africa is home to 89% of all young people living with HIV, a key population with specific challenges and needs. In-depth knowledge of service demands is needed to tailor and differentiate service delivery for this group. We evaluated HIV care preferences among young people living with HIV who were part of the PEBRA (Peer Educator Based Refill of ART) cluster-randomized trial.

Methods

The PEBRA trial evaluated a novel model of care at 20 health facilities in Lesotho, Southern Africa. In the PEBRA model, a peer educator regularly assessed participant preferences regarding antiretroviral therapy (ART) refill location, SMS notifications (for adherence, drug refill, viral load), and general care support options and delivered services accordingly over a 12-month period. We present these preferences and their changes over time.

Results

At enrolment, 41 of 123 (33.3%) chose ART refill outside the health facility, compared to 8 of 123 (6.5%) after 12 months. Among those selecting clinic-based ART refill, many preferred collecting ART during the peer educator led Saturday clinic club, 45 of 123 (36.5%) at the beginning and 55 of 123 (44.7%) at the end. SMS reminders for treatment adherence and ART refill visits were chosen by 51 of 123 (41.5%) at enrolment and 54 of 123 (44.7%) at the last assessment. Support by the peer educator was popular at the beginning (110 of 123 (89.4%)) and lower but still high at the end (85 of 123 (69.1%)). Thirteen of 123 (10.6%) participants chose support by the nurse, without the involvement of any peer educator, at the first and 21 of 123 (17.1%) at the last assessment.

Conclusion

Our longitudinal preference assessment among young people living with HIV in Lesotho showed a sustained interest in SMS notifications for adherence and refill visits as well as in additional support by a peer educator. ART refill outside the health facility was not as popular as expected; instead, medication pick-up at the facility, especially during Saturday clinic clubs, was favoured. The PEBRA trial was registered with clinicaltrials.gov (NCT03969030. Registered on 31 May 2019).

HIV cure: an acceptability scientific agenda

PURPOSE OF REVIEW

Recent years have seen major investments into HIV cure research, seeking a permanent cure or remission. The purpose of this review is to consider how this important research agenda could be broadened to include issues of acceptability and appropriateness for different populations.

RECENT FINDINGS

We discuss how the definitions of cure such as functional cure (remission) or complete cure (viral elimination) could be interpreted differently by various populations. We also discuss the different methods of cure and the importance of including Africa in cure research to ensure that emerging remedies could be trialled and utilized on the continent that bears the brunt of the AIDS pandemic.

SUMMARY

We propose that the social science research of HIV cure acceptability should be done concurrently with the basic and clinical sciences, to ensure that cure methods consider stakeholder preferences.

Patient experiences and preferences for antiretroviral therapy service provision: implications for differentiated service delivery in Northwest Ethiopia

Background

Understanding the experiences, needs, preferences, and behaviors of people living with HIV (PLHIV) are critical to tailor HIV treatment. However, there is limited empirical evidence in Ethiopia on the views of PLHIV regarding their experiences with current antiretroviral therapy (ART) services and preferred models of HIV treatment. Hence, this study aimed to explore the patients’ experiences of taking medications and preferences for ART service provision in Northwest Ethiopia.

Methods

A phenomenological study design was employed. In this study, stable and 18 years old and above PLHIVs, who had been using ART service at four public hospitals and two health centers in East Gojjam, West Gojjam and Awi zones, and Bahir Dar city administration of Amhara National Regional State, Northwest Ethiopia, were purposively selected. Fifteen in-depth interviews were conducted from July 2021 to September 2021 to collect data. ATLAS.ti version 9 software was used for coding translated transcripts. A thematic analysis approach was employed.

Findings

Participants in this study had reported positive and negative experiences in receiving ART services and also varied preferences toward ART service features. The study identified five themes on experiences for ART service and 15 attributes of ART service characteristics. The identified themes were stigma, time, availability of drugs and providers, costs for clinic visits, and provider-patient interaction. The fifteen attributes were buddy system, ART refill (individualized or group), ART packaging and labeling, drug formulation and administration, ART room labeling, distance, location of service, preferences on involvement in treatment decision-making, the person providing ART refills, provider’s attitude, spatial arrangement of ART room, time of health facility operation, time spent at clinics, and total cost of the visit.

Conclusions

The results raise awareness for the positive and negative experiences of patients informing us about barriers and supporting factors in ART service provision. They open up the potential for HIV treatment service improvement. The preferences of PLHIVs toward ART service delivery features were heterogeneous. Policy and program efforts should tailor ART services that suit patients’ needs and priorities in Ethiopia. Future research should further assess the reasons for patients’ distrust of the community ART delivery models.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-022-00452-5.

Exploring Relative Preferences for HIV Service Features Using Discrete Choice Experiments: a Synthetic Review

PURPOSE OF REVIEW

Aligning HIV treatment services with patient preferences can promote long-term engagement. A rising number of studies solicit such preferences using discrete choice experiments, but have not been systematically reviewed to seek generalizable insights. Using a systematic search, we identified eleven choice experiments evaluating preferences for HIV treatment services published between 2004 and 2020.

RECENT FINDINGS

Across settings, the strongest preference was for nice, patient-centered providers, for which participants were willing to trade considerable amounts of time, money, and travel distance. In low- and middle-income countries, participants also preferred collecting antiretroviral therapy (ART) less frequently than 1 monthly, but showed no strong preference for 3-compared with 6-month refill frequency. Facility waiting times and travel distances were also important but were frequently outranked by stronger preferences. Health facility-based services were preferred to community- or home-based services, but this preference varied by setting. In high-income countries, the availability of unscheduled appointments was highly valued. Stigma was rarely explored and costs were a ubiquitous driver of preferences. While present improvement efforts have focused on designs to enhance access (reduced waiting time, travel distance, and ART refill frequency), few initiatives focus on the patient-provider interaction, which represents a promising critical area for inquiry and investment. If HIV programs hope to truly deliver patient-centered care, they will need to incorporate patient preferences into service delivery strategies. Discrete choice experiments can not only inform such strategies but also contribute to prioritization efforts for policy-making decisions.