Preferences for care engagement among people with HIV experiencing homelessness or unstable housing: a discrete choice experiment


BACKGROUND: In San Francisco, 39% of people with HIV (PWH) experiencing homelessness or unstable housing (HUH) were virally suppressed, compared to 75% overall. We conducted a discrete choice experiment (DCE) to evaluate preferences for strategies to improve care engagement for PWH-HUH.
METHODS: From July-November 2020, we enrolled PWH-HUH at Ward 86 in our drop-in, incentivized care program ('POP-UP') and PWH-HUH in traditional primary care who had an unsuppressed viral load ('¥200 copies/mL) in the prior year. The DCE included five service attributes: single vs team of providers; incentives for clinic visit ($0, $10, $20); clinic location (Ward 86 only or additional site); drop-in vs scheduled visits; in-person only vs optional telehealth visits; and patient navigator assistance with visits. We estimated relative utilities using mixed-effects logistic regression and conducted latent class analysis to evaluate preference heterogeneity.
RESULTS: We enrolled 115 participants (59 POP-UP, 56 traditional care); 78% cisgender men, 54% used methamphetamines daily, 40% lived outdoors. Overall, strongest preferences were for same provider (β=0.94, 95%CI 0.48-1.41), incentives (β=0.56 per $5; 95%CI 0.47-0.66), and drop-in visits (β=0.47, 95%CI 0.12-0.82; Figure). Latent class analysis revealed two distinct groups: 78 (68%) preferred a flexible care model including an additional clinic location (β=0.55, 95%CI 0.25-0.84), navigator assistance (β=0.61, 95%CI 0.24-0.99), drop-in visits (β=0.61, 95%CI 0.17-1.06), and incentives (β=0.77, 95%CI 0.62-0.92); 37 (32%) preferred continuity with the same provider (β=3.12, 95%CI 2.26-3.98).

CONCLUSIONS: We identified heterogeneous care preferences among PWH-HUH via a unique DCE analysis, with one-third of respondents preferring provider continuity and two-thirds preferring a more flexible care model. All respondents preferred incentives. There was no preference for telehealth, even when facilitated by a navigator. These findings highlight the importance of in-person incentivized care for PWH-HUH with the option to choose between provider continuity and flexibility.