Preferences for the management of sexually transmitted infections in the South African health system: A discrete choice experiment

Introduction Young people have a disproportionate burden of sexually transmitted infections. Despite strengthening HIV prevention with the introduction of PrEP, STI services have remained relatively unchanged, and the standard of care remains syndromic management. We used a discrete choice experiment to investigate young peoples preferences for the diagnosis and treatment of STIs in South Africa. Methods and Findings Between 1 March 2021 and 20 April 2021, a cross-sectional online questionnaire hosted on REDCap was administered through access links sent to WhatsApp support groups for HIV PrEP users and attendees of two primary healthcare clinics and two mobile facilities in the Eastern Cape and Gauteng provinces aged between 18-49 years. Participants either self-completed the questionnaire or received support from a research assistant. We used a CLOGIT model for the initial analysis and latent class model (LCM) to establish class memberships with results displayed as odds ratios and probabilities. We enrolled 496 individuals, the majority were female (69%) and <30 years (74%). About 29% reported previous STI treatment and 20% reported current STI symptoms. The LCM showed two distinct groups within the respondent sample with different preferences for STI care. The first group comprising 68% of participants showed a strong preference for self-sampling compared to sampling by a healthcare professional (HCP) [OR 2.32; 95%-CI (1.79-3.00)] and viewed no sampling as similar to HCP sampling [OR 1.08; 95%-CI (0.92-1.26)]. There was a lower preference to receive results within 4-hours versus 2-hours [OR 0.63; 95%-CI (0.51-0.77)] and the later was viewed as equal to the receipt of results in 1-7 days by SMS or online [OR 1.03; 95%-CI (0.88-1.21). A clinic follow-up appointment for treatment was less preferable than same-day treatment [OR 0.78; 95%-CI (0.63-0.95)] while treatment from a local pharmacy was viewed with equal preference as same-day treatment [OR 1.16; 95%-CI (1.04-1.29)]. Contact slip from index patient [OR 0.86; 95%-CI (0.76-0.96)] and HCP-initiated partner notification [OR 0.63; 95%-CI (0.55-0.73)] were both less preferable than expedited partner treatment (EPT). The second group included 32% of participants with a much lower preference for self-sampling compared to sampling by HCP [OR 0.55; 95%-CI (0.35-0.86)]. No sampling was not significantly different to HCP-sampling [OR 0.85; 95%-CI (0.64-1.13)]. There was a strong preference for a 4-hour wait than a 2-hour wait for results [OR 1.45; 95%-CI (1.05-2.00)]. There was no treatment option that was significantly different from the others, however there was a strong preference for HCP-initiated partner notification than EPT [OR 1.53; 95%-CI (1.10-2.12)]. Participants were more likely to be members of group 1 than group 2 if they were aged 25-49 years compared to 18-24 years (p=0.001) and receive care from a rural compared to urban facility (p=0.011). Employed individuals were more likely to be in group 2 than group 1 (p=0.038). Conclusions Our results suggest that health service users preferred to undergo STI testing prior to treatment but there were subgroups who differed on how this should be done. This highlights the need for STI care to be flexible to accommodate different patient choices.