Evidence-based design of HIV prevention and treatment strategies for underserved populations Insights from choice modelling, cost-effectiveness analysis, and qualitative research

Despite major advances in HIV prevention and treatment, progress towards ending AIDS as a public health threat has lagged among certain populations that remain underserved by existing services. In South Africa, which carries one of the largest HIV burdens globally, gaps persist across the HIV cascade, especially among men, adolescents, and migrant populations. This threatens sustained epidemic control in a context of constrained and declining global HIV funding.
This thesis examines who remains underserved by current HIV programmes in urban South Africa, why they are underserved, and how HIV services can be better designed to align with their needs and preferences in a cost-effective manner. A mixed methods approach integrating epidemiology, behavioural economics, and health economics was used. First, quantitative and qualitative analyses to identify population segments with lower utilisation of HIV testing, prevention, and treatment services, focusing on men, migrant men, and adolescents. These analyses demonstrate that being underserved is dynamic and shaped by socio-economic status, mobility, stigma, and service design. Second, qualitative methods and discrete choice experiments were used to quantify preferences for HIV service delivery across populations and stages of the HIV care cascade. Preferences are influenced by confidentiality, respectful and non-judgemental staff and flexibility, although the relative importance of specific service attributes varies by population and over time. Third, preference data were integrated into cost-effectiveness modelling to estimate how adapting services to align with user preferences may improve uptake and efficiency prior to implementation.
The thesis contributes a practical framework for designing people-centred HIV services that are cost-effective and equitable.