HIV Treatment and Program Preferences Among Ryan White Clients in New York City in the Era of Long-Acting Injectable ART: A Discrete Choice Experiment

A discrete choice experiment involving 200 Ryan White clients in New York City revealed that a majority prefer long-acting injectable HIV treatment over daily pills, particularly among younger, Latino, and non-heterosexual individuals, despite limited prior familiarity with this regimen.

The Gist

Imagine you are at a massive buffet where the main dish is HIV treatment. For years, the only option on the menu has been a daily pill—a small, reliable, but sometimes tedious chore that you have to do every single morning.

Now, a shiny new option has arrived: Long-Acting Injectable (LAI) ART. Think of this like a "subscription service" for your health. Instead of remembering to take a pill every day, you get a shot every few months that keeps you protected. It sounds like a dream, but would everyone want it? And what other factors matter to people when they choose how to manage their health?

This study is like a taste test conducted by researchers in New York City to find out exactly what people living with HIV want.

The Setup: The "Menu" Experiment

The researchers didn't just ask, "Do you like shots?" That's too simple. Instead, they set up a Discrete Choice Experiment, which is like a "choose your own adventure" game.

They asked 200 people enrolled in the Ryan White Program (a vital safety net that helps low-income New Yorkers access HIV care) to choose between different "treatment packages." Each package had four ingredients:

1. The Medicine: Daily pills vs. Long-acting shots.
2. The Location: Where do you get it? (A clinic, a mobile van, or at home?)
3. The Support: Do you get extra help, like counseling or navigation?
4. The Reward: Do you get incentives (like gift cards) for sticking to the plan?

Crucially, they noticed that the location and support options changed depending on whether you picked the pill or the shot, making the choices feel very realistic.

The Results: Two Different Crowds

When the researchers analyzed the answers, they found that the group wasn't a monolith; they split into two distinct "flavors" of preference:

1. The "Shot Seekers" (57%): The majority of people preferred the long-acting shots.
   • Who are they? They tended to be younger (mid-40s), more likely to identify as Latino, and less likely to identify as straight/heterosexual.
   • The Catch: Even though they liked the idea of shots, most of them had never actually tried one. Only 4% of the whole group had ever used LAI before. It was like people ordering a new exotic dish they'd only seen on a menu, not on a plate.
2. The "Pill Loyalists" (43%): A significant chunk of people still preferred the daily pills.
   • Who are they? They tended to be older (late 50s) and more likely to identify as straight.

Interestingly, when it came to where they got their care or what rewards they wanted, both groups were pretty much on the same page. They all wanted good support and convenient locations.

The Big Takeaway: Familiarity is Key

The study revealed a gap between wanting something new and knowing about it. While the "Shot Seekers" were excited about the new option, many admitted they hadn't heard much about it before this survey.

It's like a new smartphone model coming out: everyone is curious, but if you don't know how it works or what it can do, you might stick with your old phone just to be safe.

Why This Matters

The researchers concluded that you can't just roll out a new medical treatment and expect everyone to love it. You have to understand who your customers are.

• The "Shot Seekers" need to know that the shots are real, safe, and available.
• The "Pill Loyalists" need to know why they might want to switch, or be reassured that sticking with pills is a valid choice.

Because of this study, the program in New York is now creating educational tools and decision guides (like a friendly menu with pictures and descriptions) to help patients and doctors have better conversations. The goal is to make sure that when a new treatment arrives, everyone—from the youngest patient to the oldest—has the information they need to choose the path that fits their life best.

Technical Summary

Technical Summary: HIV Treatment Preferences Among Ryan White Clients in NYC

1. Problem Statement
Despite significant advancements in HIV treatment, medication adherence remains a persistent barrier for many People Living with HIV (PWH). While Long-Acting Injectable (LAI) antiretroviral therapy (ART) offers a promising alternative to daily oral pills to improve adherence, there is a critical lack of data regarding patient preferences for these regimens, particularly among populations served by the Ryan White HIV/AIDS Program (RWHP). These populations often include individuals with complex social determinants of health who are frequently under-represented in clinical trials. The study addresses the gap in understanding how RWHP clients in New York City perceive and prioritize daily pills versus LAI regimens and associated service features.

2. Methodology
The study employed a Discrete Choice Experiment (DCE) to quantify patient preferences.

• Study Population: 200 clients enrolled in Ryan White HIV/AIDS Program Part A (RWPA) Medical Case Management (MCM) programs across the New York City metropolitan area (five boroughs, Rockland, Putnam, and Westchester counties). Recruitment occurred between June 2022 and January 2023.
• Experimental Design: The DCE utilized an alternative-specific design featuring four primary attributes:
  1. Type of ART Medication: Daily pills vs. Long-Acting Injectable (LAI).
  2. Service Location and Mode: Dependent on the medication type.
  3. Support: Dependent on the medication type.
  4. Rewards: Dependent on the medication type.
• Statistical Analysis: Preference estimation was conducted using Latent Class Multinomial Logit (LCML) analysis. This approach allowed for a hypothesis-free investigation of preference heterogeneity, identifying distinct subgroups (latent classes) within the population that share similar preference structures.

3. Key Results

• Preference Heterogeneity: The LCML analysis identified two distinct preference groups. A majority of participants (57%, n=114) demonstrated a higher preference for LAI regimens over daily pills, while 43% (n=86) preferred daily pills.
• Demographic Correlates: Significant demographic differences were observed between the two groups:
  • Age: LAI preferrers were significantly younger (median age 49) compared to pill preferrers (median age 58.5; p<0.001).
  • Sexual Orientation: LAI preferrers were less likely to identify as straight/heterosexual (69% vs. 82%; p=0.03).
  • Race/Ethnicity: LAI preferrers were more likely to identify as Latino/a (54% vs. 30%; p<0.001).
• Knowledge and Experience:
  • Awareness of LAI ART was higher among those who preferred it (59% vs. 41%; p=0.012).
  • Despite the preference for LAI, actual experience was low: only 4% of all participants self-reported having tried LAI ART.
• Secondary Attributes: Preferences regarding service location, support mechanisms, and rewards were found to be similar across both latent classes, suggesting that the medication delivery method (pill vs. injection) was the primary driver of choice.

4. Key Contributions

• Real-World Evidence: The study provides crucial real-world preference data from a diverse, safety-net population (RWPA clients) that is often excluded from clinical trials, ensuring that implementation strategies are equitable.
• Segmentation of Preferences: By using Latent Class Analysis, the study moves beyond aggregate averages to reveal distinct subgroups with divergent needs, specifically highlighting that younger, Latino, and non-heterosexual clients are more inclined toward LAI options.
• Identification of Knowledge Gaps: The findings highlight a disconnect between preference and familiarity; while many clients prefer LAI, the vast majority have never tried it and lack prior knowledge, indicating a need for targeted education.

5. Significance and Implications
The study underscores the necessity of tailoring HIV treatment implementation to specific patient demographics and preferences to maximize adherence. The findings suggest that a "one-size-fits-all" approach to introducing LAI ART may be ineffective.

• Clinical Practice: Providers should engage in shared decision-making, recognizing that younger and minority patients may be more receptive to LAI regimens.
• Programmatic Action: The authors note that these findings directly informed the 2023 pilot testing of educational materials and patient-provider decision-making tools designed to bridge the knowledge gap and facilitate informed regimen selection.
• Policy: The results advocate for the inclusion of diverse, real-world populations in the evaluation of innovative therapies to ensure equitable access and adoption.