Designing tailored and scalable HIV and contraceptive services for adolescents in Gauteng, South Africa: translating discrete choice experiment results to cost-effectiveness results

BACKGROUND: Youth in South Africa are disproportionately affected by STIs, HIV, and unintended pregnancies. Despite this, their utilisation of HIV and contraceptive services remains a challenge and existing approaches fail to adequately address this gap.
METHODS: We developed a framework to translate the expected impact of facility-level attributes in increasing HIV/contraceptive service uptake for youth into a cost effectiveness analysis (CEA). We used a discrete choice experiment (DCE, n=805) conducted in Gauteng, South Africa, which found that staff attitude, confidentiality, Wi-Fi, subsidized food, afternoon hours and youth-only services were preferred attributes. Based on this we simulated uptake of services adapted for these preferences. We divided preferences into modifiable attributes that could readily be adapted, and non-modifiable (e.g. staff attitude), and estimated the incremental change in uptake of services using services adapted for preferred attributes. Costs for modifiable preferences were estimated using data from a clinic in South Africa (2019 US$). We determined the incremental cost effectiveness ratio (ICER) of 15 intervention combinations, and report the results of interventions on the cost-effectiveness frontier.
RESULTS: Factors that have the greatest projected impact on uptake are friendly healthcare providers and confidential services, both of which are considered non-modifiable (18.5% 95%CI:13.0-24.0%; 8.4% 95%CI:3.0-14.0% respectively). The remaining (modifiable) factors on their own each resulted in a lower expected uptake (2.3% 95%CI:4.0%-9.00%; 3.0% 95%CI:-4.0%-10.0%; 0.3% 95%CI:-6.0%-7.0%; 0.8% 95%CI:-6.0%-7.0%) for Food, Wi-Fi, Youth only services, and Afternoon services respectively). The order of interventions on the cost-effectiveness frontier are Wi-Fi+youth-only services (ICER US$7 per additional youth accessing services), Wi-Fi+youth-only services+food (ICER US$9), followed by Wi-Fi+youth-only services+extended afternoon hours (ICER US$32) (Figure 1).


CONCLUSIONS: Combining DCE and costing analyses provides an innovative way to inform decisions on effective ways to utilise resources in the absence of implementation. Modifiable preferences have potential to cost-effectively increase the proportion of youth accessing HIV and contraceptive services.