Optimizing access to PrEP based on MSM preferences: results of a discrete choice experiment

ABSTRACT

Introduction: Despite documented effectiveness of pre-exposure prophylaxis (PrEP), PrEP uptake remains low among men who have sex with men (MSM), the population bearing the highest HIV burden in the U.S. Objectives: To elicit MSM stakeholder preferences in order to inform program development aimed at improving uptake of PrEP. METHODS: 554 MSM were recruited through social networking applications to complete a stated preference [choice-based conjoint (CBC)] survey. Respondents completed 14 choice tasks presenting experimentally varied combinations of five attributes related to PrEP administration (dosing frequency, dispensing venue, prescription practices, adherence support, and costs). Latent class analysis was used to estimate the relative importance of each attribute and preferences across seven possible PrEP delivery programs. Results: Preferences clustered into five groups. PrEP affordability was the most influential attribute across groups, followed by dosing strategy. Only one group liked daily and on-demand PrEP equally (n = 74) while the other four groups disliked the on-demand intermittent option. Monthly injectable PrEP is preferred by two (n = 210) out of the five groups, including young MSM. Two groups (n = 267) were willing to take PrEP across all the hypothetical programs. One group (n = 183) almost exclusively considered costs in their decision-making. Participants in the most racially diverse among groups (n = 88) had a very low level of interest in PrEP initiation. Conclusion: Our data suggest that PrEP uptake will be maximized by making daily PrEP affordable to MSM and streamlining PrEP consultation visits for young MSM. Young MSM should be prioritized for injectable PrEP when it becomes available. A successful PrEP program will spend resources on removing structural barriers to PrEP access and educating MSM of color, and will emphasize protection of privacy to maximize uptake among rural/suburban MSM.

KEYWORDS:

• HIV/AIDS
• men who have sex with men
• pre-exposure prophylaxis
• conjoint analysis
• patient preferences
• implementation science

Acknowledgement

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Frederick L. Altice http://orcid.org/0000-0002-7860-693X

Notes

1 Pill taken once a day, intermittent PrEP, long-lasting injectable PrEP.

2 Provider at a healthcare facility/sexually transmitted infections (STI) clinic, agency that works in lesbian-gay-bisexual-transgendered (LGBT) health/HIV prevention, pharmacy pick-up/home delivery.

3 Less demanding evaluation defined as HIV test + kidney function test, moderately demanding evaluation defined as HIV test + kidney function test + full STI panel, most demanding evaluation defined as HIV test + kidney function test + full STI panel + safer sex counseling.

4 Self-management tools, peer support groups, text messages/interactive voice response messages.

5 PrEP program is well-subsidized and easily affordable, partially subsidized and moderately affordable, not subsidized and difficult to afford.

6 Daily PrEP, provider at a healthcare facility, moderately demanding evaluation, self-management tools, moderately easy to afford PrEP.

7 Pill once a day picked up from a pharmacy, least demanding evaluation, self-management adherence tools, easy to afford.

8 Pill once a day provided by a doctor, most-demanding evaluation, peer support to facilitate adherence, and difficult to afford PrEP.

9 Affordable daily pill available within a pharmacy, with minimal testing and use of self-management adherence tools.

Additional information

Funding

Financial support for this study was provided in part by the National Institute on Drug Abuse [K24 DA017072, Altice] and the National Institute of Arthritis and Musculoskeletal and Skin Diseases [AR060231-05, Fraenkel]. This work was also supported by the Center for HIV Identification, Prevention, and Treatment Services (CHIPTS) NIMH grant P30MH058107. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH.