Willingness to pay for injectable HIV pre-exposure prophylaxis among male and female sex workers in Uganda

Abstract

Long-acting injectable cabotegravir (CAB-LA) pre-exposure prophylaxis (PrEP) has superior efficacy compared with daily oral PrEP. However, implementation in sub-Saharan Africa (SSA) is constrained by high costs and limited access. Assessing willingness to pay (WTP) is critical for the sustainable rollout of CAB-LA PrEP. This study evaluated WTP for CAB-LA PrEP among heterosexual male and female sex workers in Uganda. Within a discrete choice experiment (DCE) to evaluate CAB-LA delivery preferences, we surveyed HIV negative heterosexual male and female sex workers (SWs) in two high prevalence cities in Central and Southwestern Uganda (October-December 2024). Willingness to pay (WTP) for injectable CAB-LA, including the maximum amount per injection, was assessed among sex workers (SWs) by trained interviewers. Trained interviewers collected data on WTP for injectable CAB-LA, including the maximum amount in Ugandan shillings (UGX) per injection. Modified Poisson regression was used to identify factors associated with WTP. We enrolled 251 sex workers (SWs), including 52 (21%) males. Males had higher education (27% vs. 5%), while females had been in the industry longer (24 months vs. 18 months). Females reported higher median weekly earnings (250,000 Ugandan shillings [UGX] [US $71.43]) than males (145,000 UGX [US $41.42]). Overall, 51% of females and 42% of males expressed WTP for injectable CAB-LA, with a median WTP of 10,000 UGX [$3], compared with the current average cost of 100,000 UGX [$29] in Uganda. WTP was positively associated with residing in Kampala (adjusted prevalence ratio [aPR] 2.41; 95% confidence interval [CI] 1.64–3.55) and with older age, including ages 25–30 years (aPR 1.51; 95% CI 1.03–2.22) and 31–35 years (aPR 1.87; 95% CI: 1.25–2.92), compared with ages 18–24 years. Higher WTP was also observed among respondents with previous PrEP use (aPR 1.52; 95% CI: 1.14–2.03), while no significant differences were observed by sex (aPR 0.96; 95% CI: 0.65–1.43). This cohort of sex workers preferred injectable PrEP, but their willingness to pay remained modest. Future studies should assess the feasibility and effectiveness of out-of-pocket payment models for injectable PrEP programs.