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 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.

Patients’ preferences for telemedicine versus in-clinic consultation in primary care during the COVID-19 pandemic

“…A methodological contribution of the study lies in both a detailed description of the attribute identification process, including the number of steps and tools: (1) a literature review, (2) focus groups with targeted populations using Think Aloud technique interview guides, and (3) a ranking exercise. The rationale behind using the Think Aloud technique in DCE studies was discussed previously in the literature, but studies that describe the experience with this technique are limited [ 35 – 37 ]. The lessons learned from using the technique are described below.…”

PrEP uptake and delivery setting preferences among clients visiting six healthcare facilities in Eswatini

“…The PrEP delivery setting preferences of these people, mainly HIV testing and outpatient services, could inform on the preferences of people who do not regularly frequent health services. Another limitation is that we did not consider other potential places for PrEP refill and follow-up such as pharmacy or specific community health center [ 14 ]. A population-based survey among 2498 men and women in west Kenya showed that both men and women prefer getting PrEP in clinics (44%) followed by pharmacies (38%) [ 9 ].…”

“…MSM, sex workers), but remains scarce in general population. Existing studies suggest that groups from the general population prefer receiving PrEP from general health services rather than from a specialized clinic [ 12 – 14 ]. In the United States, a survey of 370 Black women accessing medical care for sexual health or urgent care needs showed they preferred PrEP delivery through “a regular source of healthcare” as opposed to sexually transmitted infection (STI) or family planning clinics [ 12 ].…”

“…Another US study shows that women seeking abortion preferred to receive PrEP through their usual primary care provider rather than through an abortion or sexually transmitted infection clinic [ 13 ]. A qualitative study among youth in South Africa shows that youth prefer PrEP delivery via clinic or pharmacy rather than through a youth center or doctor’s office [ 14 ]. These results differ from those observed among sub-populations such as sex workers or MSM who seems to prefer more specialized settings such as family planning clinics, non-governmental organizations or specialist consultations [ 15 – 17 ].…”

Can financial payments incentivize short-term smoking cessation in orthopaedic trauma patients? Evidence from a discrete choice experiment

“…DCEs are a well-established quantitative method that elicits stated preferences based on responses to described hypothetical scenarios. The response data are used to calculate the utility of each attribute level and the relative importance associated with each attribute [40][41][42][43][44]. Tradeoff estimates can also be calculated using the utility values.…”