School-going learners are more likely to access HIV and contraceptive care at locations with friendly providers, Wi-Fi and other value-added services: Findings from a discrete choice experiment among learners in Gauteng, South Africa

Background Many Adolescents in Sub-Saharan Africa don’t access HIV and reproductive health services optimally. To improve uptake of these services, it is important to understand the students’ preferences for how services are delivered so that implementation strategies can reflect this. Methods A discrete choice experiment (DCE) was used to elicit preferences. The DCE was conducted in 10 high schools situated in neighbourhoods of varying socio-economic status (SES) in Gauteng (South Africa). Students aged ≥15 years (Grades 9-12) were consented and enrolled in the DCE. Conditional logistic regression was used to determine preferred attributes for HIV and contraceptive service delivery. Results were stratified by gender and neighbourhood SES quintile. (1=Lowest SES; 5=Highest SES). Results The DCE was completed between 07/2018-09/2019; 805 students were enrolled (67% female; 66% 15-17 years; 51% in grades 9-10). 54% of students in quintile 1 schools had no monthly income; 38% in quintile 5 schools had access to USD7 per month. Preferences were similar for male and female students. Students strongly preferred services provided by friendly, non-judgmental staff (Odds ratio 1.63; 95% Confidence Interval: 1.55-1.72) where confidentiality was ensured (1.33; 1.26-1.40). They preferred services offered after school (1.14; 1.04-1.25) with value-added services like free Wi-Fi (1.19; 1.07-1.32), food (1.23; 1.11-1.37) and youth-only waiting areas (1.18; 1.07-1.32). Students did not have a specific location preference, but preferred not to receive services within the community (0.82; 0.74-0.91) or school (0.88; 0.80-0.96). Students attending schools in high SES neighbourhoods expressed a preference for private care (1.15; 0.98-1.35). Costs to access services were a deterrent for most students irrespective of school neighbourhood; female students were deterred by costs ≥USD3 (0.79; 0.70-0.91); males by costs ≥USD7 (0.86; 0.74-1.00) Conclusions Preferences that encourage utilisation of services do not significantly differ by gender or school neighbourhood SES. Staff attitude and confidentiality are key issues affecting students’ decisions to access HIV and contraceptive services. Addressing how healthcare providers respond to young people seeking sexual and reproductive health services is critical for improving adolescents’ uptake of these services. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was made possible by the generous support of the American People and the Presidents Emergency Plan for AIDS Relief (PEPFAR) through US Agency for International Development (USAID) under the terms of Cooperative Agreements AID-674-A-12-00029 and 72067419CA00004 to Health Economics and Epidemiology Research Office. LL was supported by the National Institute of Mental Health of the National Institutes of Health under grant number K01MH119923. The contents are the responsibility of the authors and do not necessarily reflect the views of the NIH, PEPFAR, USAID or the United States Government. The funders had no role in the study design, collection, analysis and interpretation of the data, in manuscript preparation or the decision to publish. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study protocol was reviewed and approved by the Human Research Ethics Committee (Medical) (#170213) of the University of the Witwatersrand (HREC) and the Boston University Medical Campus Institutional Review Board (H-35987) of the Boston University School of Public Health I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors