Preferences for long-acting injectable HIV pre-exposure prophylaxis service delivery among male and female sex workers in Uganda: A discrete choice experiment

Résumé

In Sub-Saharan Africa, limited data exist on the delivery of injectable HIV pre-exposure prophylaxis (PrEP). We explored service delivery preferences for injectable cabotegravir (CAB-LA) among heterosexual male sex workers (MSWs) and female sex workers (FSWs) in Uganda. We conducted a discrete choice experiment (DCE) among HIV-negative sex workers in two high HIV-prevalence Ugandan cities between October and December 2024. Participants selected from alternatives varying by location, waiting time, provider gender, and additional services. A mixed logit model identified the most valued attributes influencing preferences for CAB-LA delivery. We enrolled 251 sex workers (SWs), comprising 52 (20.7%) MSWs. MSWs were more likely to have higher education (26.9% vs 4.5%), while FSWs had been in the industry longer (24 months vs 18 months). PrEP awareness was lower among MSWs than FSWs (86.5% vs. 95.5%, p = 0.027). Overall, 39.4% reported current PrEP use. Injectable PrEP was the most preferred formulation (77.3%), and willingness to use PrEP among non-users was higher in MSWs (67.3% vs. 45.7%, p = 0.001). Regarding service delivery preferences, MSWs and FSWs both prioritized dispensing location (relative importance 81.1% MSWs, 82.9% FSWs) and provision of additional services (10.8% MSWs, 9% FSWs). In contrast, clinic waiting time and provider gender were considered the least important, with both groups assigning them a relative importance of 4%. Nevertheless, the three top-ranked CAB-LA delivery models prioritized access through private pharmacies or clinics with short waiting times, female or peer providers, and integrated health services. The preferred extra services included psychosocial support, cancer screening, and risk reduction counseling. Expanding injectable PrEP through private sector channels may improve access among SWs. Still, implementation research is needed to guide integration of supportive services and SWs' willingness to pay or co-pay for pharmacy or private clinic-based delivery.

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