Preferences for PrEP service delivery among adolescent girls and young women in remote villages in Lesotho: a discrete choice experiment

Introduction: Adolescent girls and young women (AGYW) in southern Africa are disproportionately affected by HIV. Despite increasing availability of HIV pre-exposure prophylaxis (PrEP), uptake and sustained use remain low. Existing service delivery models may not adequately meet the needs of AGYW, particularly in remote settings. We conducted a discrete choice experiment (DCE) to assess preferences for PrEP service delivery among AGYW living in Lesotho, a country with one of the highest HIV incidence rates globally. Methods: The DCE was conducted among AGYW (16-24 years) in two districts in Lesotho. Participants completed a series of binary choice tasks comparing hypothetical PrEP service delivery scenarios defined by six attributes: service location, provider type, provider characteristics, provider confidentiality, PrEP product type, and the combination of additional prevention services offered. Preferences were analysed using mixed logit and latent class models. Results: A total of 537 AGYW (median age 19 years, IQR 17-22) were included. Provider confidentiality was the strongest driver of choice, with non-confidential providers significantly less preferred ({beta} = -0.58; 95% CI -0.69 to -0.46). Compared with nurses, services delivered by ComBaCaL CHWs were preferred (0.17; 0.01 to 0.33), while those provided by doctors were less preferred (-0.15; -0.30 to 0.00). Younger female providers were preferred over older female providers (0.20; 0.04 to 0.36). Compared with the daily oral pill, both the 2-monthly injectable (-0.24; -0.39 to -0.08) and the vaginal ring (-1.02; -1.20 to -0.82) were less preferred. Differences in preferences were observed across age groups and districts. Latent class analysis identified two preference profiles, indicating variation in preferences for delivery and product characteristics. Conclusions: Preferences for PrEP delivery among AGYW in Lesotho were strongly influenced by provider confidentiality. Among some AGYW, there was openness to decentralised delivery, particularly through CHWs and community-based models, which may reduce access barriers in remote settings. Product preferences were varied, and not all options were acceptable. Differences by age group and district indicate that no single delivery model will meet all needs. Building on the current standard of care, offering acceptable options in accessible and confidential ways may support PrEP uptake.