A discrete choice experiment engaging South African MSM youth in early-stage HIV prevention method design to achieve high uptake and adherence
To engage a vulnerable population in the design of new HIV prevention medications and strategies.
After consulting directly with our target population of young South African men who have sex with men, we conducted a discrete choice experiment to determine their preferences for an HIV-prevention product.
Compared to men who have sex with women only, the men in our target population preferred injections over implants. They preferred a product with longer duration and access via a pharmacy or clinic over other community locations.
Men who have sex with men (MSM) are disproportionately impacted by HIV worldwide. In South Africa, the estimated prevalence of HIV among MSM is 26.9 percent—a sobering fact that shows how important prevention efforts are to this population. Unfortunately, persistent discrimination and stigmatization for MSM inhibits them from engaging in HIV prevention strategies. Though existing HIV prevention methods such as oral PrEP have proven to be effective, low adherence, especially among MSM, remains a crippling issue for the success of HIV prevention in Africa. Long Acting HIV prevention methods may reduce adherence challenges. Involving MSM in the early stage of the design and testing of long-acting approaches presents an opportunity to help protect this vulnerable population.
The iPrevent study, a collaborative effort of the RTI Women’s Global Health Imperative and the Desmond Tutu Research Foundation, set out to combat stigma and discrimination in HIV prevention among MSM. We embarked on in-depth consultations with those working with MSM and MSM leaders to optimize MSM engagement.
These stakeholder consultations revealed safety and confidentiality as a high priority for MSM, which led us to change the study design and implementation. Stakeholders stressed the importance of hosting the study at a location that is not branded for HIV prevention nor for targeting MSM, which led the team to rent an unbranded office in the Cape Town city center.
Stakeholders also highlighted the importance of confidentiality in trust-building to create greater openness for MSM to share their perspectives, as well as increase individuals’ willingness to participate in the study and adhere to the study requirements. Additionally, they urged that the study team make themselves visible with MSM by attending social events and venues where they may be, such as local clubs and a pride event, and urged the team to undergo sensitization training. In addition to responding to these recommendations, the iPrevent team ultimately adjusted sampling methods to include direct recruitment through engagement with MSM in social settings – a method which fostered greater rapport and trust with participants.
Having responded to MSM-specific needs, the iPrevent study successfully enrolled 190 MSM in a discrete choice experiment to determine their preferences for an HIV-prevention product. This method is designed to elicit product preferences by examining the trade-offs individuals make when choosing between alternative product designs. In this study, the products were categorized by five attributes with up to four levels each, including:
- product form (implant or injections)
- dose frequency (two, six, or twelve months)
- where the product is available (clinic, pharmacy, community distribution, mobile clinic)
- soreness after product insertion (mild or moderate)
- and location of product (buttocks, thigh, upper arm).
The study’s findings revealed that MSM, compared to men who have sex with women only (n=216), were more likely to prefer injections for HIV prevention and dislike implants. They preferred a product with longer duration and access via a pharmacy or health clinic location over other community locations.
Identifying MSM-specific preferences for HIV prevention and responding to these desires should ultimately improve the uptake and adherence to these products, which would be a huge win for HIV prevention. Following the successful implementation of iPrevent, the collaborative team is now embarking on a clinical study with MSM and non-MSM in South Africa called SAMURAI. In the SAMURAI study, participants will be asked to use placebo versions of long-acting injectables and implants for six months each. SAMURAI will assess MSM and non-MSM’s acceptability of these methods, their safety experiences, and other social-behavioral aspects of using these methods within the context of their lives. Through this research, we hope to foster greater engagement of South African men–of all sexualities–in HIV prevention.