Search

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., Competing Interests: Dr. Sharma reports grants from The National Institute of Mental Health during the conduct of the study. Dr. Celum reports grants from The National Institutes of Mental Health during the conduct of the study and personal fees from Merck and Gilead Sciences outside the submitted work. The other authors declare that they have nothing to disclose., (© 2020 The Authors.)

Objective: The aim of this study was to appropriately plan for rollout and monitor impact of oral preexposure prophylaxis (PrEP). It is important to understand PrEP continuation and come to a consensus on how best to measure PrEP continuation. This study reviews data on PrEP continuation to document how it is reported, and to compare continuation over time and across populations., Design: A systematic review and meta-analysis., Methods: We searched MEDLINE, Embase and Global Health and reviewed abstracts from HIV conferences from 2017 to 2018 for studies reporting primary data on PrEP continuation. Findings were summarized along a PrEP cascade and continuation was presented by population at months 1, 6 and 12, with random-effects meta-analysis., Results: Of 2578 articles and 596 abstracts identified, 41 studies were eligible covering 22 034 individuals. Continuation data were measured and reported inconsistently. Results showed high discontinuation at month 1 and persistent discontinuation at later time points in many studies. Pooled continuation estimates were 66% at month 1 [n = 5348; 95% confidence interval (95% CI): 48-82], 63% at month 6 (n = 13 629; 95% CI: 48-77) and 71% at month 12 (n = 14 933; 95% CI: 60-81; higher estimate than previous timepoints due to inclusion of different studies). Adequate data were not available to reliably compare estimates across populations., Conclusion: This review found that discontinuation at one month was high, suggesting PrEP initiations may be a poor measure of effectiveness. Continuation declined further over time in many studies, indicating existing cross-sectional indicators may not be adequate to understand PrEP use patterns. Studies do not measure continuation consistently, and consensus is needed.

Introduction: Heterosexual men are not considered a key population in the HIV response and are mostly absent from pre-exposure prophylaxis (PrEP) studies to date. Yet, South African men face considerable HIV risk. We estimate the incremental cost-effectiveness of providing oral PrEP, injectable PrEP, or a combination of both to heterosexual South African men to assess whether providing PrEP would efficiently use resources., Methods: Epidemiological and costing models estimated the one-year costs and outcomes associated with PrEP use in 3 scenarios. PrEP uptake was estimated for younger (aged 18-24) and older (aged 25-49) men using a discrete choice experiment. Scenarios were compared with a baseline scenario of male condom use, while a health system perspective was used to estimate discounted lifetime costs averted per HIV infection. PrEP benefit was estimated in disability-adjusted life years (DALYs) averted. Uncertainty around the estimated incremental cost-effectiveness ratios (ICERs) was assessed using deterministic and probabilistic sensitivity analyses., Results: No PrEP intervention scenarios were cost-effective for both age groups at a willingness-to-pay threshold of $1175/DALY averted. The lowest ICER ($2873/DALY averted) was for the provision of oral PrEP to older men, although probability of cost-effectiveness was just 0.26%. Results found that ICERs were sensitive to HIV incidence and antiretroviral coverage., Conclusions: This study estimates that providing PrEP to heterosexual South African men is not cost-effective at current cost-effectiveness thresholds. Given the ICERs' sensitivity to several variables, alongside the heterogeneity of HIV infection among South African men, PrEP may be cost-effective for older men with high incidence and other subgroups based on locality and race. We recommend further investigation to better identify and target these groups.

There is some evidence that female sex workers (FSWs) receive greater earnings for providing unprotected sex. In 2003, the landscape of the fight against HIV/AIDS dramatically changed in India with the introduction of Avahan, the largest HIV prevention programme implemented globally. Using a unique, cross-sectional bio-behavioural dataset from 3591 FSWs located in the four Indian states where Avahan was implemented, we estimate the economic loss faced by FSWs who always use condoms. We estimate the causal effect of condom use on the price charged during the last paid sexual intercourse using the random targeting of Avahan as an instrumental variable. Results indicate that FSWs who always use condoms face an income loss of 65% (INR125, US$2.60) per sex act compared to peers providing unprotected sex, consistent with our expectations. The main finding confirms that clients have a preference for unprotected sex and that policies aiming at changing clients' preferences and at improving the bargaining power of FSWs are required to limit the spread of HIV., (© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Poor peri-urban sanitation is a significant public health problem, likely to become more important as the world rapidly urbanizes. However, little is known about the role of consumer demand in increasing peri-urban sanitation quality, especially for tenants using shared sanitation as only their rental choices can be observed in the market. We analyzed data on existing housing markets collected between 9 Jun and 6 Jul 2017 using the Hedonic Pricing Method (HPM) to capture the percentage of rent attributable to sanitation quality (n = 933). We also conducted discrete choice experiments (DCEs) to obtain willingness to pay (WTP) estimates for specific sanitation components (n = 1087), and explored the implications by estimating the proportion of plots for which improved sanitation quality would generate a higher return on investment for landlords than building a place for an additional tenant to live. The HPM attributed 18% of rental prices to sanitation (∼US$8.10 per month), but parameters for several components were poorly specified due to collinearity and low overall prevalence of some products. DCEs revealed that tenants were willing to pay $2.20 more rent per month for flushing toilets on plots with running water and $3.39 more per month for solid toilet doors, though they were willing to pay little for simple hole covers and had negative WTP for adding locks to doors (-$1.04). Solid doors and flushing toilets had higher rent increase to cost ratios than other ways landlords commonly invested in their plots, especially as the number of tenant households on a plot increased. DCEs yielded estimates generally consistent with and better specified than HPM and may be useful to estimate demand in other settings. Interventions leveraging landlords' profit motives could lead to significant improvements in peri-urban sanitation quality, reduced diarrheal disease transmission, and increased well-being without subsidies or infrastructure investments by government or NGOs., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Voluntary medical male circumcision (VMMC) is effective in reducing the risk of human immunodeficiency virus (HIV). However, countries like Tanzania have high HIV prevalence but low uptake of VMMC. We conducted a discrete-choice experiment to evaluate the preferences for VMMC service attributes in a random sample of 325 men aged 18 years or older from the general population in 2 Tanzanian districts, Njombe and Tabora. We examined the preference for financial incentives in the form of a lottery ticket or receiving a guaranteed transport voucher for attendance at a VMMC service. We created a random-parameters logit model to account for individual preference heterogeneity and a latent class analysis model for identifying groups of men with similar preferences to test the hypothesis that men who reported sexually risky behaviors (i.e., multiple partners and any condomless sex in the past 12 months) may have a preference for participation in a lottery-based incentive. Most men preferred a transport voucher (84%) over a lottery ticket. We also found that offering a lottery-based financial incentive may not differentially attract those with greater sexual risk. Our study highlights the importance of gathering local data to understand preference heterogeneity, particularly regarding assumptions around risk behaviors.

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.

Introduction: HIV self-testing (HIVST) is recommended by the World Health Organization in addition to other testing modalities to increase uptake of HIV testing, particularly among harder-to-reach populations. This study provides the first empirical evidence of the costs of door-to-door community-based HIVST distribution in Malawi, Zambia and Zimbabwe., Methods: HIVST kits were distributed door-to-door in 71 sites across Malawi, Zambia and Zimbabwe from June 2016 to May 2017. Programme expenditures, supplemented by on-site observation and monitoring and evaluation data were used to estimate total economic and unit costs of HIVST distribution, by input and site. Inputs were categorized into start-up, capital and recurrent costs. Sensitivity and scenario analyses were performed to assess the impact of key parameters on unit costs., Results: In total, 152,671, 103,589 and 93,459 HIVST kits were distributed in Malawi, Zambia and Zimbabwe over 12, 11 and 10 months respectively. Across these countries, 43% to 51% of HIVST kits were distributed to men. The average cost per HIVST kit distributed was US$8.15, US$16.42 and US$13.84 in Malawi, Zambia and Zimbabwe, respectively, with pronounced intersite variation within countries driven largely by site-level fixed costs. Site-level recurrent costs were 70% to 92% of full costs and 20% to 62% higher than routine HIV testing services (HTS) costs. Personnel costs contributed from 26% to 52% of total costs across countries reflecting differences in remuneration approaches and country GDP., Conclusions: These early door-to-door community HIVST distribution programmes show large potential, both for reaching untested populations and for substantial economies of scale as HIVST programmes scale-up and mature. From a societal perspective, the costs of HIVST appear similar to conventional HTS, with the higher providers' costs substantially offsetting user costs. Future approaches to minimizing cost and/or maximize testing coverage could include unpaid door-to-door community-led distribution to reach end-users and integrating HIVST into routine clinical services via direct or secondary distribution strategies with lower fixed costs., (© 2019 World Health Organization; licensed by IAS.)

Discrete choice experiments (DCEs) are economic tools that elicit the stated preferences of respondents. Because of their increasing importance in informing the design of health products and services, it is critical to understand the extent to which DCEs give reliable predictions outside of the experimental context. We systematically reviewed the literature of published DCE studies comparing predictions to choices made in reality; we extracted individual-level data to estimate a bivariate mixed-effects model of pooled sensitivity and specificity. Eight studies met the inclusion criteria, and six of these gave sufficient data for inclusion in a meta-analysis. Pooled sensitivity and specificity estimates were 88% (95% CI 81, 92%) and 34% (95% CI 23, 46%), respectively, and the area under the SROC curve (AUC) was 0.60 (95% CI 0.55, 0.64). Results indicate that DCEs can produce reasonable predictions of health-related behaviors. There is a great need for future research on the external validity of DCEs, particularly empirical studies assessing predicted and revealed preferences of a representative sample of participants.

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.

Background: Although voluntary medical male circumcision (VMMC) reduces the risk of HIV acquisition, demand for services is lower among men in most at-risk age groups (ages 20-34 years). A randomized controlled trial was conducted to assess the effectiveness of locally-tailored demand creation activities (including mass media, community mobilization, and targeted service delivery) in increasing uptake of campaign-delivered VMMC among men aged 20-34 years. We conducted an economic evaluation to understand the intervention's cost and cost-effectiveness., Setting: Tanzania (Njombe and Tabora regions)., Methods: Cost data were collected on surgery, demand creation activities, and monitoring and supervision related to VMMC implementation across clusters in both trial arms, as well as start-up activities for the intervention arms. The Decision Makers' Program Planning Tool was used to estimate the number of HIV infections averted and related cost savings, given the total VMMCs per cluster. Disability-adjusted life years were calculated and used to estimate incremental cost-effectiveness ratios., Results: Client load was higher in the intervention arms than in the control arms: 4394 vs. 2901 in Tabora and 1797 vs. 1025 in Njombe, respectively. Despite additional costs of tailored demand creation, demand increased more than proportionally: mean costs per VMMC in the intervention arms were $62 in Tabora and $130 in Njombe, and in the control arms $70 and $191, respectively. More infections were averted in the intervention arm than in the control arm in Tabora (123 vs. 67, respectively) and in Njombe (164 vs. 102, respectively). The intervention dominated the control because it was both less costly and more effective. Cost savings were observed in both regions stemming from the antiretroviral treatment costs averted as a result of the VMMCs performed., Conclusions: Spending more to address local preferences as a way to increase uptake of VMMC can be cost-saving.