Female sex worker preferences for HIV pre-exposure prophylaxis delivery in Uganda: A discrete choice experiment

Cisgender female sex workers (FSWs) in sub-Saharan Africa have a high risk of HIV acquisition, highlighting the need for innovative approaches to expand coverage of evidence-based HIV prevention methods, including oral pre-exposure prophylaxis (PrEP). Our study aimed to identify FSWs' preferences for a PrEP delivery model with structured choices for delivery location, services offered, and adherence support. We conducted a discrete choice experiment (DCE) with female sex workers (FSWs) aged 18 and above at the Most At-Risk Population Initiative (MARPI) clinic in Kampala, Uganda, from October to November 2023. Participants were recruited consecutively. To identify the most preferred PrEP delivery model, we designed eight choice sets using a D-efficient design. Each set included three PrEP service options and an opt-out. Options varied by provider, delivery location, channel, and support services. Participants selected their preferred option in each set. Preferences and trade-offs were analyzed using a panel mixed model, and the highest median utility identified the top model. Overall, 203 participants completed the DCE. The median age was 24 years (interquartile range [IQR] 20-32). Most FSWs preferred receiving PrEP from a healthcare worker at the clinic with short message service (SMS) reminders for adherence support (median utility score 0.87; interquartile range [IQR] 0.82, 0.94). This preference remained consistent across all age groups, with a median utility score of 0.88 for ages 15-19, 0.87 for ages 20-24, and 0.85 for ages >= 25. FSWs preferred to receive PrEP care directly from providers at healthcare facilities and highlighted the need for additional support in the form of SMS reminders to improve adherence and prevent HIV acquisition. This preferred model, if implemented, could increase prevention coverage and inform future approaches to delivering PrEP through the Uganda National PrEP Program.