Top

Published in:

Open Access 01-12-2021 | Human Immunodeficiency Virus | Research article

A qualitative study to identify critical attributes and attribute-levels for a discrete choice experiment on oral pre-exposure prophylaxis (PrEP) delivery among young people in Cape Town and Johannesburg, South Africa

Authors: Janan J. Dietrich, Millicent Atujuna, Gugulethu Tshabalala, Stefanie Hornschuh, Mamakiri Mulaudzi, Michelle Koh, Nadia Ahmed, Richard Muhumuza, Andrew S. Ssemata, Kennedy Otwombe, Linda-Gail Bekker, Janet Seeley, Neil A. Martinson, Fern Terris-Prestholt, Julie Fox

Published in: BMC Health Services Research | Issue 1/2021

Abstract

Background

The uptake and adherence of daily oral PrEP has been poor in high-risk populations in South Africa including young people. We used qualitative research methods to explore user preferences for daily and on-demand oral PrEP use among young South Africans, and to inform the identification of critical attributes and attribute-levels for quantitative analysis of user preferences, i.e. a discrete choice experiment (DCE).

Methods

Data were collected between September and November 2018 from eight group discussions and 20 in-depth interviews with young people 13 to 24 years in Cape Town and Johannesburg. Using a convenience sampling strategy, participants were stratified by sex and age. Interviewers used a semi-structured interview guide to discuss several attributes (dosing regimen, location, costs, side effects, and protection period) for PrEP access and use. Group discussions and in-depth interviews were audio-recorded, transcribed verbatim and translated to English. We used framework analysis to explore context-specific attributes and attribute-levels for delivering oral PrEP in South Africa. The adolescent community advisory board, expert and study team opinions were consulted for the final DCE attributes and levels.

Results

We enrolled 74 participants who were 51% (n = 38/74) male, had a median age of 18.5 [Interquartile range = 16–21.25] years, 91% (n = 67/74) identified as heterosexual and 49% (n = 36/74) had not completed 12th grade education. Using the qualitative data, we identified five candidate attributes including (1) dosing regimen, (2) location to get PrEP, (3) cost, (4) route of administration and (5) frequency. After discussions with experts and the study team, we revised the DCE to include the following five attributes and levels: dosing regime: daily, and on-demand PrEP; location: private pharmacy, public clinic, mobile clinic, ATM); cost: free-of-charge, R50 (~2GBP), R265 (~12GBP); side effects: nausea, headache, rash; and duration of protection: fulltime protection versus when PrEP is used).

Conclusions

There is limited literature on qualitative research methods describing the step-by-step process of developing a DCE for PrEP in adolescents, especially in resource-constrained countries. We provide the process followed for the DCE technique to understand user preferences for daily and on-demand oral PrEP among young people in South Africa.

Available only for authorised users

Nicol MR, Adams JL, Kashuba AD. HIV PrEP trials: the road to success. Clin Investigation. 2013;3(3). https://doi.org/10.4155/cli.12.155.

Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399–410. https://doi.org/10.1056/NEJMoa1108524.CrossRefPubMedPubMedCentral

Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375(9):830–9.

Bekker LG, Roux S, Sebastien E, Yola N, Amico KR, Hughes JP, et al. Daily and non-daily pre-exposure prophylaxis in African women (HPTN 067/ADAPT Cape Town trial): a randomised, open-label, phase 2 trial. The lancet HIV. 2018;5(2):e68–78. https://doi.org/10.1016/s2352-3018(17)30156-x.CrossRefPubMed

Marrazzo JM, Ramjee G, Richardson BA, Gomez K, Mgodi N, Nair G, et al. Tenofovir-based preexposure prophylaxis for HIV infection among African women. N Engl J Med. 2015;372(6):509–18. https://doi.org/10.1056/NEJMoa1402269.CrossRefPubMedPubMedCentral

Van Damme L, Corneli A, Ahmed K, Agot K, Lombaard J, Kapiga S, et al. Preexposure prophylaxis for HIV infection among African women. N Engl J Med. 2012;367(5):411–22. https://doi.org/10.1056/NEJMoa1202614.CrossRefPubMedPubMedCentral

Abdool Karim Q, Abdool Karim SS, Frohlich JA, Grobler AC, Baxter C, Mansoor LE, et al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science (New York, NY). 2010;329(5996):1168–74. https://doi.org/10.1126/science.1193748.CrossRef

UNAIDS. Getting to Zero: HIV in Eastern and Southern Africa. Johannesburg, South Africa: UNAIDS; 2013. Accessed.

McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet (London, England). 2016;387(10013):53–60. https://doi.org/10.1016/s0140-6736(15)00056-2.CrossRef

10.

Murnane PM, Celum C, Mugo N, Campbell JD, Donnell D, Bukusi E, et al. Efficacy of preexposure prophylaxis for HIV-1 prevention among high-risk heterosexuals: subgroup analyses from a randomized trial. AIDS (London, England). 2013;27(13):2155–60. https://doi.org/10.1097/QAD.0b013e3283629037.CrossRef

11.

Thigpen MC, Kebaabetswe PM, Paxton LA, Smith DK, Rose CE, Segolodi TM, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367(5):423–34. https://doi.org/10.1056/NEJMoa1110711.CrossRefPubMed

12.

Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–99. https://doi.org/10.1056/NEJMoa1011205.CrossRefPubMedPubMedCentral

13.

Choopanya K, Martin M, Suntharasamai P, Sangkum U, Mock PA, Leethochawalit M, et al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet (London, England). 2013;381(9883):2083–90. https://doi.org/10.1016/s0140-6736(13)61127-7.CrossRef

14.

WHO. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Geneva, Switzerland: WHO; 2015. https://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en/. Accessed 02 June 2020.

15.

Molina JM, Capitant C, Spire B, Pialoux G, Cotte L, Charreau I, et al. On-demand Preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med. 2015;373(23):2237–46. https://doi.org/10.1056/NEJMoa1506273.CrossRef

16.

National Department of Health. PrEP Implementation Pack: South Africa 2016-2017. Pretoria, South Africa: NDoH; 2019. https://www.prepwatch.org/wp-content/uploads/2017/07/SA_ImplementationPack.pdf. Accessed 02 June 2020.

17.

Ajayi AI, Mudefi E, Yusuf MS, Adeniyi OV, Rala N, Goon DT. Low awareness and use of pre-exposure prophylaxis among adolescents and young adults in high HIV and sexual violence prevalence settings. Medicine. 2019;98(43):e17716. https://doi.org/10.1097/md.0000000000017716.CrossRefPubMedPubMedCentral

18.

UNAIDS. A snapshot of men and HIV in South Africa. UNAIDS: Geneva, Switzerland; 2017. https://www.unaids.org/en/regionscountries/countries/southafrica. Accessed 02 June 2020.

19.

Ryan M, Bate A, Eastmond CJ, Ludbrook A. Use of discrete choice experiments to elicit preferences. Quality in health care : QHC. 2001;10(Suppl 1(Suppl 1)):i55–60. https://doi.org/10.1136/qhc.0100055.CrossRefPubMed

20.

Abiiro GA, Leppert G, Mbera GB, Robyn PJ, De Allegri M. Developing attributes and attribute-levels for a discrete choice experiment on micro health insurance in rural Malawi. BMC Health Serv Res. 2014;14:235. https://doi.org/10.1186/1472-6963-14-235.CrossRefPubMedPubMedCentral

21.

Quaife M, Eakle R, Cabrera Escobar MA, Vickerman P, Kilbourne-Brook M, Mvundura M, et al. Divergent preferences for HIV prevention: a discrete choice experiment for multipurpose HIV prevention products in South Africa. Med Decision Making. 2018;38(1):120–33. https://doi.org/10.1177/0272989x17729376.CrossRef

22.

Coast J, Horrocks S. Developing attributes and levels for discrete choice experiments using qualitative methods. J Health Serv Res Policy. 2007;12(1):25–30. https://doi.org/10.1258/135581907779497602.CrossRefPubMed

23.

Dubov A, Ogunbajo A, Altice FL, Fraenkel L. Optimizing access to PrEP based on MSM preferences: results of a discrete choice experiment. AIDS Care. 2019;31(5):545–53. https://doi.org/10.1080/09540121.2018.1557590.CrossRefPubMed

24.

Kuteesa MO, Weiss HA, Abaasa A, Nash S, Nsubuga RN, Newton R, et al. Feasibility of conducting HIV combination prevention interventions in fishing communities in Uganda: a pilot cluster randomised trial. PLoS One. 2019;14(3):e0210719. https://doi.org/10.1371/journal.pone.0210719.CrossRefPubMedPubMedCentral

25.

Lancaster KE, Lungu T, Bula A, Shea JM, Shoben A, Hosseinipour MC, et al. Preferences for pre-exposure prophylaxis service delivery among female sex Workers in Malawi: a discrete choice experiment. AIDS Behav. 2020;24(5):1294–303. https://doi.org/10.1007/s10461-019-02705-3.CrossRefPubMed

26.

Nash S, Dietrich J, Ssemata AS, Herrera C, O'Hagan K, Else L, et al. Combined HIV adolescent prevention study (CHAPS): comparison of HIV pre-exposure prophylaxis regimens for adolescents in sub-Saharan Africa-study protocol for a mixed-methods study including a randomised controlled trial. Trials. 2020;21(1):900. https://doi.org/10.1186/s13063-020-04760-x.CrossRefPubMedPubMedCentral

27.

Adams J, Bateman B, Becker F, Cresswell T, Flynn D, McNaughton R, et al. Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: systematic review, qualitative study and discrete choice experiment. Health Technol Assessment (Winchester, England). 2015;19(94):1–176. https://doi.org/10.3310/hta19940.CrossRef

28.

Galea JT, Kinsler JJ, Salazar X, Lee SJ, Giron M, Sayles JN, et al. Acceptability of pre-exposure prophylaxis as an HIV prevention strategy: barriers and facilitators to pre-exposure prophylaxis uptake among at-risk Peruvian populations. Int J STD AIDS. 2011;22(5):256–62. https://doi.org/10.1258/ijsa.2009.009255.CrossRefPubMedPubMedCentral

29.

Smith DM. The apartheid city and beyond: urbanization and social change in South Africa: Routledge; 2003.CrossRef

30.

Statistics South Africa. Mid-year population estimates. Pretoria, South Africa. 2019. https://www.statssa.gov.za/publications/P0302/P03022019.pdf. Accessed 02 June 2020.

31.

Simbayi LC, Zuma K, Zungu N, Moyo S, Marinda E, Jooste S, et al. South African national HIV prevalence, incidence, behaviour and communication survey, 2017. Cape Town, South Africa: HSRC Press; 2019. http://www.hsrc.ac.za/en/departments/saph/HAST_National_HIV_Survey. Accessed 05 June 2020.

32.

Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. https://doi.org/10.1186/1471-2288-13-117.CrossRefPubMedPubMedCentral

33.

IBM Corp. IBM SPSS Statistics for Windows. Armonk, NY: IBM Corp; 2017. https://hadoop.apache.org. Accessed 17th June 2020.

34.

Desmond Tutu HIV Foundation. Mobile Services. 2019. https://desmondtutuhivfoundation.org.za/what-we-do/mobile-services-tutu/. Accessed 16 May 2020.

35.

Kuhfeld WF. Marketing research methods in SAS: experimental design, choice, conjoint, and graphical techniques. Cary: SAS Institute Inc; 2005. Available from: https://www.scribd.com/document/52395109/Marketing-Research-Methods-In-Sas.

36.

Minnis AM, Atujuna M, Browne EN, Ndwayana S, Hartmann M, Sindelo S, et al. Preferences for long-acting pre-exposure prophylaxis (PrEP) for HIV prevention among south African youth: results of a discrete choice experiment. J Int AIDS Soc. 2020;23(6):e25528. https://doi.org/10.1002/jia2.25528.CrossRefPubMedPubMedCentral

37.

Test Positive Awareness Network. Truvada for PrEP (HIV prevention). 2016. https://www.thebodypro.com/article/truvada-for-prep-hiv-prevention. Accessed 01 July 2020.

38.

Avrett S. Can PrEP on Demand for HIV Prevention Work in the U.S.? Experts Answer Your Questions. 2018. https://www.thebodypro.com/article/can-prep-on-demand-for-hiv-prevention-work-in-the-. Accessed 01 July 2020.

39.

PNGImage. Free Tag Icon. 2020. https://pngimage.net/free-tag-icon-png-8/. Accessed 01 July 2020.

40.

PNGImage. Cash Clipart. 2020. https://pngimage.net/cash-clipart-png-3/. Accessed 01 July 2020.

41.

VectorStock. Face palm emoticon vector image. 2020. https://www.vectorstock.com/royalty-free-vector/face-palm-emoticon-vector-12786472. Accessed 01 July 2020.

42.

Clipart Library. Collection of itchy cliparts. 2018. http://clipart-library.com/itchy-cliparts.html. Accessed 01 July 2020.

43.

Terris-Prestholt F, Hanson K, MacPhail C, Vickerman P, Rees H, Watts C. How much demand for new HIV prevention technologies can we really expect? Results from a discrete choice experiment in South Africa. PLoS One. 2013;8(12):e83193. https://doi.org/10.1371/journal.pone.0083193.CrossRefPubMedPubMedCentral

44.

Eisingerich AB, Wheelock A, Gomez GB, Garnett GP, Dybul MR, Piot PK. Attitudes and acceptance of oral and parenteral HIV preexposure prophylaxis among potential user groups: a multinational study. PLoS One. 2012;7(1):e28238. https://doi.org/10.1371/journal.pone.0028238.CrossRefPubMedPubMedCentral

45.

Celum C, Hallett TB, Baeten JM. HIV-1 prevention with ART and PrEP: mathematical modeling insights into resistance, effectiveness, and public health impact. J Infect Dis. 2013;208(2):189–91. https://doi.org/10.1093/infdis/jit154.CrossRefPubMedPubMedCentral

46.

Conroy AA, McGrath N, van Rooyen H, Hosegood V, Johnson MO, Fritz K, et al. Power and the association with relationship quality in South African couples: Implications for HIV/AIDS interventions. Social Sci Med (1982). 2016;153:1–11. https://doi.org/10.1016/j.socscimed.2016.01.035.CrossRef

47.

Roberts ST, Heffron R, Ngure K, Celum C, Kurth A, Curran K, et al. Preferences for daily or intermittent pre-exposure prophylaxis regimens and ability to anticipate sex among HIV uninfected members of Kenyan HIV serodiscordant couples. AIDS Behav. 2014;18(9):1701–11. https://doi.org/10.1007/s10461-014-0804-1.CrossRefPubMedPubMedCentral

48.

Skinner D, Mfecane S. Stigma, discrimination and the implications for people living with HIV/AIDS in South Africa. SAHARA J : journal of Social Aspects of HIV/AIDS Research Alliance. 2004;1(3):157–64. https://doi.org/10.1080/17290376.2004.9724838.CrossRef

49.

Treves-Kagan S, El Ayadi AM, Pettifor A, MacPhail C, Twine R, Maman S, et al. Gender, HIV testing and stigma: the association of HIV testing behaviors and community-level and individual-level stigma in rural South Africa differ for men and women. AIDS Behav. 2017;21(9):2579–88. https://doi.org/10.1007/s10461-016-1671-8.CrossRefPubMedPubMedCentral

50.

Nkosi B, Seeley J, Ngwenya N, McHunu SL, Gumede D, Ferguson J, et al. Exploring adolescents and young people's candidacy for utilising health services in a rural district, South Africa. BMC Health Serv Res. 2019;19(1):195. https://doi.org/10.1186/s12913-019-3960-1.CrossRefPubMedPubMedCentral

51.

Wood K, Jewkes R. Blood blockages and scolding nurses: barriers to adolescent contraceptive use in South Africa. Reprod Health Matters. 2006;14(27):109–18. https://doi.org/10.1016/s0968-8080(06)27231-8.CrossRefPubMed

52.

Hodges-Mameletzis I, Fonner VA, Dalal S, Mugo N, Msimanga-Radebe B, Baggaley R. Pre-exposure prophylaxis for HIV prevention in women: current status and future directions. Drugs. 2019;79(12):1263–76. https://doi.org/10.1007/s40265-019-01143-8.CrossRefPubMed

53.

Laher F, Salami T, Hornschuh S, et al. Willingness to use HIV prevention methods among vaccine efficacy trial participants in Soweto, South Africa: discretion is important. BMC Public Health. 2020;20:1669. https://doi.org/10.1186/s12889-020-09785-0.

54.

de Bekker-Grob EW, Ryan M, Gerard K. Discrete choice experiments in health economics: a review of the literature. Health Econ. 2012;21(2):145–72. https://doi.org/10.1002/hec.1697.CrossRefPubMed

55.

Mangham LJ, Hanson K, McPake B. How to do (or not to do) ... Designing a discrete choice experiment for application in a low-income country. Health Policy Plan. 2009;24(2):151–8. https://doi.org/10.1093/heapol/czn047.CrossRefPubMed

56.

Dunne T, Bishop L, Avery S, Darcy S. A review of effective youth engagement strategies for mental health and substance use interventions. J Adolesc Health. 2017;60(5):487–512. https://doi.org/10.1016/j.jadohealth.2016.11.019.CrossRefPubMed

57.

Reed SJ, Miller RL. The benefits of youth engagement in HIV-preventive structural change interventions. Youth Soc. 2014;46(4):529–47. https://doi.org/10.1177/0044118x12443372.CrossRefPubMed

58.

Bailey JL, Molino ST, Vega AD, Badowski M. A review of HIV pre-exposure prophylaxis: the female perspective. Infect Dis Ther. 2017;6(3):363–82. https://doi.org/10.1007/s40121-017-0159-9.CrossRefPubMedPubMedCentral

59.

Gill K, Pidwell T, Dietrich J, Gray G, Bennie T, Kayamba F, et al., A demonstration open label study to assess the acceptability, safety and use of Truvada pre-exposure prophylaxis in healthy, HIV-uninfected adolescents, 15–19 years of age. 9th IAS Conference on HIV Science; 2017.

Title: A qualitative study to identify critical attributes and attribute-levels for a discrete choice experiment on oral pre-exposure prophylaxis (PrEP) delivery among young people in Cape Town and Johannesburg, South Africa
Authors: Janan J. Dietrich
Millicent Atujuna
Gugulethu Tshabalala
Stefanie Hornschuh
Mamakiri Mulaudzi
Michelle Koh
Nadia Ahmed
Richard Muhumuza
Andrew S. Ssemata
Kennedy Otwombe
Linda-Gail Bekker
Janet Seeley
Neil A. Martinson
Fern Terris-Prestholt
Julie Fox
Publication date: 01-12-2021
Publisher: BioMed Central
Keyword: Human Immunodeficiency Virus
Published in: BMC Health Services Research / Issue 1/2021
Electronic ISSN: 1472-6963
DOI: https://doi.org/10.1186/s12913-020-05942-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

A qualitative study to identify critical attributes and attribute-levels for a discrete choice experiment on oral pre-exposure prophylaxis (PrEP) delivery among young people in Cape Town and Johannesburg, South Africa

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2021

Rural-urban and gender differences in the association between community care services and elderly individuals’ mental health: a case from Shaanxi Province, China

State of the practice of health information systems: a survey study amongst health care professionals in intellectual disability care

Distance to primary care facilities and healthcare utilization for preschool children in rural northwestern Burkina Faso: results from a surveillance cohort

Adaptations and modifications to a co-designed intervention and its clinical implementation: a qualitative study in Denmark

The factors influencing clinician use of hypertension guidelines in different resource settings: a qualitative study investigating clinicians’ perspectives and experiences

The predictive role of sickness absence spell durations in associations with inpatient- and specialized outpatient care among a population-based Swedish twin sample