Preferences for transitional HIV care among people living with HIV recently released from prison in Zambia: a discrete choice experiment

Introduction No studies from sub-Saharan Africa have attempted to assess HIV service delivery preferences among incarcerated people living with HIV as they transition from prisons to the community ("releasees"). We conducted a discrete choice experiment (DCE) to characterize releasee preferences for transitional HIV care services in Zambia to inform the development of a differentiated service delivery model to promote HIV care continuity for releasees. Methods Between January and October 2019, we enrolled a consecutive sample of 101 releasees from a larger cohort prospectively following 296 releasees from five prisons in Zambia. We administered a DCE eliciting preferences for 12 systematically designed choice scenarios, each presenting three hypothetical transitional care options. Options combined six attributes: (1) clinic type for post-release HIV care; (2) client focus of healthcare workers; (3) transitional care model type; (4) characteristics of transitional care provider; (5) type of transitional care support; and (6) HIV status disclosure support. We analysed DCE choice data using a mixed logit model, with coefficients describing participants' average ("mean") preferences for each option compared to the standard of care and their distributions describing preference variation across participants. Results Most DCE participants were male (n = 84, 83.2%) and had completed primary school (n = 54, 53.5%), with 29 (28.7%) unemployed at follow-up. Participants had spent an average of 8.2 months in the community prior to the DCE, with 18 (17.8%) reporting an intervening episode of re-incarceration. While we observed significant preference variation across participants (p < 0.001 for most characteristics), releasees were generally averse to clinics run by community-based organizations versus government antiretroviral therapy clinics providing post-release HIV care (mean preference = -0.78, p < 0.001). On average, releasees most preferred livelihood support (mean preference = 1.19, p < 0.001) and HIV care support (mean preference = 1.00, p < 0.001) delivered by support groups involving people living with HIV (mean preference = 1.24, p < 0.001). Conclusions We identified preferred characteristics of transitional HIV care that can form the basis for differentiated service delivery models for prison releasees. Such models should offer client-centred care in trusted clinics, provide individualized HIV care support delivered by support groups and/or peer navigators, and strengthen linkages to programs providing livelihood support.