Preferred TB prevention boosts acceptance among people with HIV in Uganda

Tuberculosis preventive treatment (TPT) can protect people living with HIV from developing active TB, but little is known about which regimens patients would actually choose when offered alternatives. Corresponding author Hélène E. Aschmann and colleagues set out to gather actionable evidence about those preferences to inform policy and new regimen development. They worked with adults engaged in care at an HIV clinic in Kampala, Uganda, and used a discrete choice experiment to probe decision-making. Each participant completed nine random choice tasks. In every task the participant first picked between two hypothetical TPT regimens that varied by number of pills, frequency, duration, whether antiretroviral dosage would need adjustment, and side effects; they then indicated whether they would accept the chosen regimen or take no treatment. The research team simulated predicted regimen choice using hierarchical Bayesian estimation of individual preference weights. Four hundred people were enrolled and 394 provided high-quality answers; the median age was 44, 71.8% were female, and 91.4% had previously received TPT. This setup allowed the researchers to see both what people prefer and what they would actually accept.

The experiment revealed strong overall willingness to accept TPT but clear drivers of rejection. Across the nine tasks, 60.2% (237/394) of participants accepted every selected regimen, 39.3% (155/394) accepted some regimens, and only 0.5% (2/394) accepted none. Regimens that required antiretroviral dosage adjustment were much more likely to be unacceptable (adjusted odds ratio, aOR 27.4, 95% confidence interval 18.5–40.7). Higher pill counts also reduced acceptability: regimens requiring 10 pills per dose were far less acceptable than those with 1 or 5 pills (aOR 24.5, 95% CI 16.6–36.3). The team ran choice simulations to predict how regimen availability would change uptake. If only 6 months of daily isoniazid (6H) were available, 11.9% would prefer no TPT. But adding a 4-pill, fixed-dose combination 3HP option alongside 6H increased predicted overall acceptance from 88.1% to 98.8% (predicted choice: 3HP 94.5%, 6H 4.4%, no TPT 1.2%).

These findings point to clear, practical steps for increasing TPT uptake among people living with HIV. While most participants were willing to accept treatment, features such as the need to adjust antiretroviral dosage and a high pill burden strongly deterred acceptance. Offering patient-preferred options — in this study a 4-pill, fixed-dose combination 3HP regimen — could move acceptance from high to nearly universal. For policy makers and program planners, the message is that regimen design matters: avoiding interactions that require antiretroviral dose changes and minimizing the number of pills per dose are likely to increase real-world use. The study provides concrete, preference-based evidence that can guide which regimens to make available at clinics and which characteristics to prioritize in future TPT development. By aligning available options with what patients prefer, health systems could improve preventive care and reduce the burden of TB among people living with HIV.