Preferences for Pre-exposure Prophylaxis Service Delivery Among Female Sex Workers in Malawi: A Discrete Choice Experiment

  • Kathryn E. LancasterEmail author
  • Thandie Lungu
  • Agatha Bula
  • Jaclyn M. Shea
  • Abigail Shoben
  • Mina C. Hosseinipour
  • Racquel E. Kohler
  • Irving F. Hoffman
  • Vivian F. Go
  • Carol E. Golin
  • Stephanie B. Wheeler
  • William C. Miller
Original Paper


Female sex workers (FSW) in Malawi have among the highest HIV prevalence estimates worldwide. Daily oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, yet preferences for PrEP delivery among FSW are lacking. Eight focus group discussions, a literature review, and cognitive interviews were conducted to identify modifiable PrEP delivery attributes and inform discrete-choice experiment (DCE) development for FSW in Lilongwe. Enrolled FSW received an interviewer-assisted DCE. Data were analyzed using mixed logit regression. Dispensing location was most preferred, followed by the provision of additional services. Women preferred receiving PrEP at family planning clinics or non-governmental organization run drop-in centers. Cervical cancer screening was the most preferred additional service, while pregnancy testing and partner risk reduction counseling were less valued. This study was the first study to examine PrEP delivery preferences in Malawi using DCE—a powerful elicitation tool to apply to other key populations at risk for HIV.


Pre-exposure prophylaxis Sex workers Women Africa 



We would like to acknowledge Dylane Davis, Emmanuel Zalira, the Family Planning Association of Malawi, and UNC Project Malawi for their contributions and support to this project. We are also grateful to the participants who courageously shared their time, thoughts, and stories. This work was supported by the University of North Carolina at Chapel Hill Center for AIDS Research, an NIH funded program (P30 AI50410).

Author Contributions

KEL and TL had overall responsibility for implementing the study, and conceived and designed the study, analyzed the data, and led the manuscript writing. KEL, TL, MCH, VFG, CEG, SBW, and WCM contributed to developing the study concept and design. TL, AG, and JS contributed to data collection. JS, AS, and REK assisted with data analysis and results interpretation. JS, AS, MCH, REK, IFH, VGO, CEG, SBW, and WCM contributed to drafting the manuscript. All authors reviewed the manuscript critically for intellectual content. All authors read and approved the final draft of the submitted manuscript.


This work was supported by the University of North Carolina at Chapel Hill Center for AIDS Research, an NIH funded program (P30 AI50410).

Compliance with Ethical Standards

Conflict of interest

Authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human subjects were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Kathryn E. Lancaster
    • 1
    Email author
  • Thandie Lungu
    • 2
  • Agatha Bula
    • 2
  • Jaclyn M. Shea
    • 3
  • Abigail Shoben
    • 4
  • Mina C. Hosseinipour
    • 2
    • 5
  • Racquel E. Kohler
    • 6
  • Irving F. Hoffman
    • 5
  • Vivian F. Go
    • 3
  • Carol E. Golin
    • 3
    • 5
  • Stephanie B. Wheeler
    • 7
  • William C. Miller
    • 1
  1. 1.Division of Epidemiology, College of Public HealthThe Ohio State UniversityColumbusUSA
  2. 2.University of North Carolina Project-MalawiLilongweMalawi
  3. 3.Department of Health Behavior, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillUSA
  4. 4.Division of Biostatistics, College of Public HealthThe Ohio State UniversityColumbusUSA
  5. 5.Division of Infectious Diseases, School of MedicineThe University of North Carolina at Chapel HillChapel HillUSA
  6. 6.Harvard T.H. Chan School of Public HealthBostonUSA
  7. 7.Department of Health Policy and Management, Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillUSA

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