Divergent Preferences for HIV Prevention: A Discrete Choice Experiment for Multipurpose HIV Prevention Products in South Africa

Quaife, Matthew; Eakle, Robyn; Escobar, Maria A. Cabrera; Vickerman, Peter; Kilbourne-Brook, Maggie; Mvundura, Mercy; Delany‐Moretlwe, Sinead; Terris‐Prestholt, Fern

doi:10.1177/0272989x17729376

Cited by 93 publications

(106 citation statements)

References 47 publications

(65 reference statements)

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“…Example products (an oral tablet, an injectable, a microbicide gel, and a intravaginal ring) were given to respondents to examine in an effort to imagine real‐life use, and interviewers answered any questions they had. In an additional DCE, preferences for product characteristics were consistent with prior expectations, demonstrating participant understanding of the protective benefits of products (Quaife et al, ; Quaife et al, ).…”

Section: Empirical Methodssupporting

confidence: 67%

The effect of HIV prevention products on incentives to supply condomless commercial sex among female sex workers in South Africa

et al. 2018

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Evidence suggests that economic factors play an important role in commercial sex work, in particular that condomless sex commands a price premium relative to condom‐protected sex. This paper explores whether the use of a new HIV prevention product, with 100% efficacy but modeled after pre‐exposure prophylaxis (PrEP), could change the price and quantity of condomless commercial sex supplied. We collected stated preference data from 122 HIV‐negative female sex workers in urban South Africa, using a repeated choice experiment to simulate the impact of using PrEP on choices. Results suggest that the price premium for condomless sex would decrease by 73% with PrEP use and the quantity of condomless sex is predicted to increase by a factor of 2.27. Act price does not significantly affect choices without protection but strongly influences choices under full HIV protection. The utility offered by condoms reduces by around 15% under PrEP use. Because new HIV prevention products do not protect against other STIs or pregnancy, the unintended consequences of introducing HIV prevention products should be closely monitored, whereas users should not face stigma or blame for reacting rationally to exogenous changes to market conditions.

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Section: Empirical Methodssupporting

confidence: 67%

The effect of HIV prevention products on incentives to supply condomless commercial sex among female sex workers in South Africa

et al. 2018

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“…Based on the stated preferences in the DCE, incorporating contraceptive characteristics into HIV prevention products would result in a meaningful increase in product use, reinforcing evidence of unmet demand for MPTs among many groups [11,12]. Results indicate that multi-purpose prevention products are likely to be cost-effective among younger women (aged [16][17][18][19][20][21][22][23][24] and FSWs compared to current condom provision, with scenario 3, oral PrEP plus a MPT ring, and scenario 5, the full range of MPT products, estimated to be the most cost-effective. However, despite being cost-effective, our uptake projections suggest that products are unlikely to achieve dramatic decreases in HIV incidence.…”

Section: Discussionmentioning

confidence: 99%

“…Including STI preventative attributes in addition to HIV and pregnancy does not markedly change cost-effectiveness estimates. Tornado plots for the most cost-effective scenario (oral PrEP plus MPT ring) are included in File S6, and demonstrate cost-effectiveness in females aged [16][17][18][19][20][21][22][23][24] and FSWs for all parameter variations.…”

Section: Sensitivity Analysesmentioning

confidence: 99%

“…Although the financial and regulatory burden of MPT development is likely to be high, their benefits may also be large, not least because of synergistic impacts across health outcomes. Firstly, products offering more than one indication may be more attractive to some potential users than single-purpose products, particularly the combination of contraceptive and HIV prevention properties [21,22]. Secondly, MPT use could crowd-in protection from lesser valued attributes.…”

Section: Introductionmentioning

confidence: 99%

“…This paper presents a cost-effectiveness analysis which estimates the incremental benefits and health system costs of single-and multi-purpose prevention products, compared to current practice of condom use and male circumcision prevalence. Cost-effectiveness is modelled across three female groups due to differences in epidemiology and HIV risk in each: younger women (aged [16][17][18][19][20][21][22][23][24], older women (aged and female sex workers (FSWs).…”

Section: Introductionmentioning

confidence: 99%

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The cost‐effectiveness of multi‐purpose HIV and pregnancy prevention technologies in South Africa

et al. 2018

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IntroductionA number of antiretroviral HIV prevention products are efficacious in preventing HIV infection. However, the sexual and reproductive health needs of many women extend beyond HIV prevention, and research is ongoing to develop multi‐purpose prevention technologies (MPTs) that offer dual HIV and pregnancy protection. We do not yet know if these products will be an efficient use of constrained health resources. In this paper, we estimate the cost‐effectiveness of combinations of candidate multi‐purpose prevention technologies (MPTs), in South Africa among general population women and female sex workers (FSWs).MethodsWe combined a cost model with a static model of product impact based on incidence data in South Africa to estimate the cost‐effectiveness of five candidate co‐formulated or co‐provided MPTs: oral PrEP, intravaginal ring, injectable ARV, microbicide gel and SILCS diaphragm used in concert with gel. We accounted for the preferences of end‐users by predicting uptake using a discrete choice experiment (DCE). Product availability and protection were systematically varied in five potential rollout scenarios. The impact model estimated the number of infections averted through decreased incidence due to product use over one year. The comparator for each scenario was current levels of male condom use, while a health system perspective was used to estimate discounted lifetime treatment costs averted per HIV infection. Product benefit was estimated in disability‐adjusted life years (DALYs) averted. Benefits from contraception were incorporated through adjusting the uptake of these products based on the DCE and through estimating the costs averted from avoiding unwanted pregnancies. We explore the additional impact of STI protection through increased uptake in a sensitivity analysis.ResultsAt central incidence rates, all single‐ and multi‐purpose scenarios modelled were cost‐effective among FSWs and women aged 16–24, at a governmental willingness‐to‐pay threshold of $1175/DALY averted (range: $214–$810/DALY averted among non‐dominant scenarios), however, none were cost‐effective among women aged 25–49 (minimum $1706/DALY averted). The cost‐effectiveness of products improved with additional protection from pregnancy. Estimates were sensitive to variation in incidence assumptions, but robust to other parameters.ConclusionsTo the best of our knowledge, this is the first study to estimate the cost‐effectiveness of a range of potential MPTs; suggesting that MPTs will be cost‐effective among higher incidence FSWs or young women, but not among lower incidence older women. More work is needed to make attractive MPTs available to potential users who could use them effectively.

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Modelling the effect of market forces on the impact of introducing human immunodeficiency virus pre‐exposure prophylaxis among female sex workers

et al. 2020

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Pre-exposure prophylaxis (PrEP) to prevent human immunodeficiency virus (HIV) enables female sex workers (FSWs) to protect themselves from HIV without relying on clients using condoms. Yet, because PrEP reduces HIV risk, financial incentives to not use condoms may lead to risk compensation: reductions in condom use and/or increases in commercial sex, and may reduce the price of unprotected sex. In this analysis, we integrate market forces into a dynamic HIV transmission model to assess how risk compensation could change the impact of PrEP among FSWs and clients. We parameterise how sexual behavior may change with PrEP use among FSWs using stated preference data combined with economic theory. Our projections suggest the impact of PrEP is sensitive to risk compensatory behaviors driven by changes in the economics of sex work. Condom substitution could reduce the impact of PrEP on HIV incidence by 55%, while increases in the frequency of commercial sex to counter decreases in the price charged for unprotected sex among PrEP users could entirely mitigate the impact of PrEP. Accounting for competition between PrEP users and nonusers exacerbates this further. Alternative scenarios where increases in unprotected sex among PrEP users are balanced by decreases in non-PrEP users have the opposite effect, resulting in PrEP having much greater impact. Intervention studies need to determine how HIV prevention products may change the economics of sex work and provision of unprotected sex to enable a better understanding of their impact. K E Y W O R D S economics of sex work, HIV prevention, pre-exposure prophylaxis, South Africa, transmission model This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

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Divergent Preferences for HIV Prevention: A Discrete Choice Experiment for Multipurpose HIV Prevention Products in South Africa

Cited by 93 publications

References 47 publications

The effect of HIV prevention products on incentives to supply condomless commercial sex among female sex workers in South Africa

The effect of HIV prevention products on incentives to supply condomless commercial sex among female sex workers in South Africa

The cost‐effectiveness of multi‐purpose HIV and pregnancy prevention technologies in South Africa

Modelling the effect of market forces on the impact of introducing human immunodeficiency virus pre‐exposure prophylaxis among female sex workers

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