Background:
Dynamic choice models for delivering HIV prevention may increase coverage for persons at risk. Data are limited on actual product choices made by clients and the impact of choice-based delivery models on prevention coverage. Outpatient departments (OPD) in health facilities in rural sub-Saharan Africa account for a high proportion of new HIV diagnoses, but are an understudied entry point to biomedical HIV prevention, including dynamic choice models.
Methods:
We conducted an individually randomized trial of a dynamic choice HIV prevention (DCP) intervention vs. standard-of-care referral to prevention services (SOC) among adults with current or anticipated risk of HIV exposure seen at OPD clinics in rural Kenya and Uganda (SEARCH; NCT04810650). DCP included 1) product choice (daily oral PrEP [TDF/XTC] or post-exposure prophylaxis [PEP]) with option to switch over time, 2) service location choice, 3) HIV self-testing option, 4) 24/7 phone access to clinician, and 5) provider training on client-centered care. Primary outcome over 48 weeks was biomedical covered time (proportion of follow-up covered by PrEP/PEP), assessed via self-report; secondary outcomes included coverage during periods of retrospectively self-assessed HIV risk.
Results:
We enrolled 403 participants from April-July 2021, (197 DCP, 206 SOC): 61% women, 37% ages 15-24 years, 25% serodifferent partner, 88% HIV status unknown partner, 7% with prior PrEP or PEP use. In the DCP arm, 86% ever chose PrEP, 13% PEP over 48 weeks; selection of HIV self-testing increased from 26% to 51% and of out-of-facility visits from 8% to 52% during follow-up. Among 376/403 (93%) with outcomes ascertained, mean biomedical covered time was higher in DCP (47%) vs. SOC (18%); a difference of 29.2% (95% CI 22.7-35.7%; p< 0.001). Effect sizes were similar among men and women (28% and 31% higher coverage in the intervention arm, respectively). Intervention effect on coverage during periods at risk of HIV was larger; mean at-risk covered time was 65% in the DCP arm vs. 26% in SOC (difference 38.6%; 95%CI: 31.0-46.2%; p< 0.001).
Conclusions:
In this randomized study, a dynamic choice prevention intervention with choice of PrEP/PEP, visit location, and HIV testing, plus client-centered care resulted in two-fold greater time covered by a biomedical prevention option compared to SOC among both men and women at elevated risk of HIV seen in a general outpatient department.