Patient preferences for HIV service delivery models: A discrete choice experiment in Kisumu, Kenya

Background: Novel “differentiated service delivery” models for HIV
treatment that reduce clinic visit frequency, minimize waiting time, and
deliver treatment in the community promise retention improvement for HIV
treatment in Sub-Saharan Africa.  Quantitative assessments of
differentiated service delivery (DSD) feature most preferred by patient
populations do not widely exist but could inform the selection and
prioritization of different types of DSD models. Methods: We used a
discrete choice experiment (DCE) to elicit patient preferences for HIV
treatment services and how they differ across DSD models. We surveyed
adults aged >18 years, enrolled in HIV care for >6 months
between February and March 2019 at four facilities in Kisumu County,
Kenya.  DCE offered patients a series of comparisons between
three treatment models, each of which varied in seven attributes: ART
refill location, the quantity of ART dispensed at each refill, medication
pick-up hours, type of adherence support, clinical visit frequency, staff
attitude, and professional cadre of the person providing ART
refills.  We used a hierarchical Bayesian model to estimate
attribute importance and the relative desirability of care
characteristics, latent class analysis (LCA) for groups of preferences,
and mixed logit model for willingness to trade analysis. Results: Of 242
patients, 128 (53.8%) were females and 150 (62.8%) lived in rural
areas.  Patients placed the greatest importance on ART refill
location [19.5% (95%CI 18.4, 20.6)] and adherence support [19.5% (95%CI
18.7, 20.3)], followed by staff attitude [16.1% (95%CI 15.1, 17.2)]. In
the mixed logit, patients preferred the nice attitude of the staff
(coefficient=1.60), refill ART health center (Coeff=1.58), and individual
adherence support (Coeff=1.54), 3 or 6 months for ART refill (Coeff=0.95
& 0.80, respectively) and pharmacists (instead of lay health
workers) providing ART refill (Coeff=0.64). No differences were observed
by gender or urbanicity. LCA revealed two distinct groups (59.5%
vs.40.5%). Conclusions: Participants preferred 3 to 6-month refill
intervals or clinic visit spacing, which DSD provides for stable patients.
While DSD has also encouraged community ART group options, our results
suggest strong patient preferences for ART refills from health centers or
by pharmacists over lay caregivers or community members. These preferences
held across gender and urban/rural subpopulations.