Informing targeted HIV self-testing: a protocol for discrete choice experiments in Malawi, Zambia and Zimbabwe (original) (raw)

Applying user preferences to optimize the contribution of HIV self‐testing to reaching the “first 90” target of UNAIDS Fast‐track strategy: results from discrete choice experiments in Zimbabwe

Journal of the International AIDS Society

Introduction: New HIV testing strategies are needed to reach the United Nations' 90-90-90 target. HIV self-testing (HIVST) can increase uptake, but users' perspectives on optimal models of distribution and post-test services are uncertain. We used discrete choice experiments (DCEs) to explore the impact of service characteristics on uptake along the testing cascade. Methods: DCEs are a quantitative survey method that present respondents with repeated choices between packages of service characteristics, and estimate relative strengths of preferences for service characteristics. From June to October 2016, we embedded DCEs within a population-based survey following door-to-door HIVST distribution by community volunteers in two rural Zimbabwean districts: one DCE addressed HIVST distribution preferences; and the other preferences for linkage to confirmatory testing (LCT) following self-testing. Using preference coefficients/utilities, we identified key drivers of uptake for each service and simulated the effect of changes of outreach and static/public clinics' characteristics on LCT. Results: Distribution and LCT DCEs surveyed 296/329 (90.0%) and 496/594 (83.5%) participants; 81.8% and 84.9% had ever-tested, respectively. The strongest distribution preferences were for: (1) free kitsa 1increaseinthekitpricewasassociatedwithadisutility(U)ofAˋ2.017;(2)door−to−doorkitdelivery(U=+1.029)relativetocollectionfrompublic/outreachclinic;(3)telephonehelplineforpretestsupportrelativetoin−personornosupport(U=+0.415);(4)distributorsfromown/localvillage(U=+0.145)versusthosefromexternalcommunities.ParticipantswhohadneverHIVtestedvaluedphonehelplinesmorethanthosepreviouslytested.ThestrongestLCTpreferenceswere:(1)immediateantiretroviraltherapy(ART)availability:U=+0.614andU=+1.052forpublicandoutreachclinics,respectively;(2)freeservices:a1 increase in the kit price was associated with a disutility (U) of À2.017; (2) door-to-door kit delivery (U = +1.029) relative to collection from public/outreach clinic; (3) telephone helpline for pretest support relative to in-person or no support (U = +0.415); (4) distributors from own/local village (U = +0.145) versus those from external communities. Participants who had never HIV tested valued phone helplines more than those previously tested. The strongest LCT preferences were: (1) immediate antiretroviral therapy (ART) availability: U = +0.614 and U = +1.052 for public and outreach clinics, respectively; (2) free services: a 1increaseinthekitpricewasassociatedwithadisutility(U)ofAˋ2.017;(2)doortodoorkitdelivery(U=+1.029)relativetocollectionfrompublic/outreachclinic;(3)telephonehelplineforpretestsupportrelativetoinpersonornosupport(U=+0.415);(4)distributorsfromown/localvillage(U=+0.145)versusthosefromexternalcommunities.ParticipantswhohadneverHIVtestedvaluedphonehelplinesmorethanthosepreviouslytested.ThestrongestLCTpreferenceswere:(1)immediateantiretroviraltherapy(ART)availability:U=+0.614andU=+1.052forpublicandoutreachclinics,respectively;(2)freeservices:a1 user fee increase decreased utility at public (U = À0.381) and outreach clinics (U = À0.761); (3) proximity of clinic (U = À0.38 per hour walking). Participants reported willingness to link to either location; but never-testers were more averse to LCT. Simulations showed the importance of availability of ART: ART unavailability at public clinics would reduce LCT by 24%. Conclusions: Free HIVST distribution by local volunteers and immediately available ART were the strongest relative preferences identified. Accommodating LCT preferences, notably ensuring efficient provision of ART, could facilitate "resistant testers" to test while maximizing uptake of post-test services.

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

AIDS (London, England), 2018

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

Heterogeneous HIV Testing Preferences in an Urban Setting in Tanzania: Results from a Discrete Choice Experiment

PLoS ONE, 2014

Background: Efforts to reduce Human Immunodeficiency Virus (HIV) transmission through treatment rely on HIV testing programs that are acceptable to broad populations. Yet, testing preferences among diverse at-risk populations in Sub-Saharan Africa are poorly understood. We fielded a population-based discrete choice experiment (DCE) to evaluate factors that influence HIV-testing preferences in a low-resource setting. Methods: Using formative work, a pilot study, and pretesting, we developed a DCE survey with five attributes: distance to testing, confidentiality, testing days (weekday vs. weekend), method for obtaining the sample for testing (blood from finger or arm, oral swab), and availability of HIV medications at the testing site. Cluster-randomization and Expanded Programme on Immunization (EPI) sampling methodology were used to enroll 486 community members, ages 18-49, in an urban setting in Northern Tanzania. Interviewer-assisted DCEs, presented to participants on iPads, were administered between September 2012 and February 2013. Results: Nearly three of five males (58%) and 85% of females had previously tested for HIV; 20% of males and 37% of females had tested within the past year. In gender-specific mixed logit analyses, distance to testing was the most important attribute to respondents, followed by confidentiality and the method for obtaining the sample for the HIV test. Both unconditional assessments of preferences for each attribute and mixed logit analyses of DCE choice patterns suggest significant preference heterogeneity among participants. Preferences differed between males and females, between those who had previously tested for HIV and those who had never tested, and between those who tested in the past year and those who tested more than a year ago. Conclusion: The findings suggest potentially significant benefits from tailoring HIV testing interventions to match the preferences of specific populations, including males and females and those who have never tested for HIV.

I will choose when to test, where I want to test': investigating young people's preferences for HIV self-testing in Malawi and Zimbabwe

AIDS (London, England), 2017

The current study identifies young people's preferences for HIV self-testing (HIVST) delivery, determines the relative strength of preferences and explores underlying behaviors and perceptions to inform youth-friendly services in southern Africa. A mixed methods design was adopted in Malawi and Zimbabwe and includes focus group discussions, in-depth interviews and discrete choice experiments. The current study was conducted during the formative phase of cluster-randomized trials of oral-fluid HIVST distribution. Young people aged 16-25 years were purposively selected for in-depth interviews (n = 15) in Malawi and 12 focus group discussions (n = 107) across countries. Representative samples of young people in both countries (n = 341) were administered discrete choice experiments on HIVST delivery, with data analyzed to estimate relative preferences. The qualitative results provided additional depth and were triangulated with the quantitative findings. There was strong concordance...

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

BMJ Open, 2020

IntroductionApproximately 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 analysisThe 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 b...

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

Expert review of pharmacoeconomics & outcomes research, 2018

To assess patients' preferences for HIV testing in Colombia. 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. 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. This study suggests that patients&#3...

Understanding preferences for HIV care and treatment in Zambia: Evidence from a discrete choice experiment among patients who have been lost to follow-up

PLoS medicine, 2018

In public health HIV treatment programs in Africa, long-term retention remains a challenge. A number of improvement strategies exist (e.g., bring services closer to home, reduce visit frequency, expand hours of clinic operation, improve provider attitude), but implementers lack data about which to prioritize when resource constraints preclude implementing all. We used a discrete choice experiment (DCE) to quantify preferences for a number of potential clinic improvements to enhance retention. We sought a random sample of HIV patients who were lost to follow-up (defined as >90 days late for their last scheduled appointment) from treatment facilities in Lusaka Province, Zambia. Among those contacted, we asked patients to choose between 2 hypothetical clinics in which the following 5 attributes of those facilities were varied: waiting time at the clinic (1, 3, or 5 hours), distance from residence to clinic (5, 10, or 20 km), ART supply given at each refill (1, 3, or 5 months), hours...

Choice in HIV testing: the acceptability and anticipated use of a self-administered at-home oral HIV test among South Africans

African Journal of AIDS Research, 2016

Combination HIV prevention is being widely promoted by funders. This strategy aims to offer HIV prevention choices that can be selected and combined to decrease HIV risk in ways that fit with each individual's situation. Treatment as prevention and pre-exposure prophylaxis are two new evidence-based strategies to decrease HIV incidence, both of which require high HIV testing rates to be effective, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a goal of 90% of HIV-positive individuals knowing their status by 2030. However, HIV testing rates in many countries remain suboptimal. Just as no single HIV prevention method is ideal for all people in all situations, no single HIV testing modality is likely to be acceptable to everyone. By offering HIV testing choices, we may be able to increase testing rates. However, many lowresourced countries have been slow to take up new HIV testing options such as the selfadministered at-home oral HIV test that is currently available in the United States. In this paper, we present findings from 20 in-depth interviews, conducted in 2010, documenting opinions about self-administered at-home oral HIV testing, a testing modality still largely unavailable in Africa. Participants were clients of three primary healthcare clinics in South Africa. Self-testing was seen as enabling confidentiality/privacy, saving time, and facilitating testing together with partners. However, concerns were raised about psychological distress when testing at home without a counsellor. Some suggested this concern could be minimised by having experienced clinic-based

Optimizing Differentiated HIV Treatment Models in Urban Zimbabwe: Assessing Patient Preferences Using a Discrete Choice Experiment

AIDS and Behavior, 2020

Differentiated service delivery holds great promise for streamlining the delivery of health services for HIV. This study used a discrete choice experiment to assess preferences for differentiated HIV treatment delivery model characteristics among 500 virally suppressed adults on antiretroviral therapy in Harare, Zimbabwe. Treatment model characteristics included location, consultation type, healthcare worker cadre, operation times, visit frequency and duration, and cost. A mixed effects logit model was used for parameter estimates to identify potential preference heterogeneity among participants, and interaction effects were estimated for sex and age as potential sources of divergence in preferences. Results indicated that participants preferred health facility-based services, less frequent visits, individual consultations, shorter waiting times, lower cost and, delivered by respectful and understanding healthcare workers. Some preference heterogeneity was found, particularly for lo...

Patient preferences for HIV service delivery models; a Discrete Choice Experiment in Kisumu, Kenya

PLOS Global Public Health

Novel “differentiated service delivery” models for HIV treatment that reduce clinic visit frequency, minimize waiting time, and deliver treatment in the community promise retention improvement for HIV treatment in Sub-Saharan Africa. Quantitative assessments of differentiated service delivery (DSD) feature most preferred by patient populations do not widely exist but could inform selection and prioritization of different DSD models. We used a discrete choice experiment (DCE) to elicit patient preferences of HIV treatment services and how they differ across DSD models. We surveyed 18+year-olds, enrolled in HIV care for ≥6 months between February-March, 2019 at four facilities in Kisumu County, Kenya. DCE offered patients a series of comparisons between three treatment models, each varying across seven attributes: ART refill location, quantity of dispensed ART at each refill, medication pick-up hours, type of adherence support, clinical visit frequency, staff attitude, and professiona...