Improving pre-exposure prophylaxis service delivery to gay men and other men who have sex with men in South Africa: Generating novel insights with a nudgeathon

Open Letter

“Indlela – Behavioral Insights for Better Health” (https://indlela.org), a novel behavioral science unit focused on improving health services and achieving better health outcomes in South Africa was established in 2019 (Thirumurthy et al., 2023). Primary goals of the unit are to build capacity in applying behavioral science in the public sector and to build the evidence base for behavioral solutions through rapid tests and dissemination. To support these goals, the team developed the NUDGE Handbook, a pragmatic behavioral design framework (Mandimika et al., 2023). Even with the NUDGE framework, it was challenging for key knowledge holders and experts (i.e., clients, health care providers, implementers, policy makers) to incorporate behavioral insights into their programs. It was equally challenging for behavioral scientists on the Indlela team to design solutions without the deep knowledge and lived experience of the stakeholders.

We developed a process that combined Indlela’s technical expertise and stakeholder knowledge to rapidly co-create behavioral solutions to address behavior change challenges and advance public health goals. We identified nudgeathons – used in other settings and for other behavioral change challenges – as a promising approach (Udall et al., 2019). A nudgeathon is a rapid, structured design process that leverages behavioral insights to generate potential interventions. Indlela designed and hosted our first nudgeathon in Johannesburg (March 2023) to identify opportunities to improve HIV pre-exposure prophylaxis (PrEP) service delivery for gay men and other men who have sex with men (MSM) in South Africa.

In South Africa, gay men and other MSM bear a disproportionate HIV burden, with 30% prevalence (UNAIDS, 2023); in Eastern and Southern Africa more than 40% of new infections are associated with vulnerable population groups (including MSM) and their partners (UNAIDS, 2023). In 2016 South Africa started offering PrEP to populations at increased risk of HIV acquisition and now has one of the largest populations of PrEP initiators (UNAIDS, 2023). However, both uptake (PrEP initiation) and persistence (remaining on PrEP) are lower than optimal given the expected benefits for this population in South Africa. In addition to significant structural barriers to PrEP uptake and persistence, prior research also points to important behavioral barriers and opportunities to mitigate structural barriers through behavioral interventions (Paladhi et al., 2022).

To capture these potential solutions to increase PrEP uptake and persistence amongst gay men and other MSM, we designed and conducted a two-day nudgeathon in partnership with 26 diverse key stakeholders implementing PrEP programming in South Africa, including health care providers, health program implementers, policy makers and government officials. Stakeholders were purposively assigned to one of 5 teams; all teams included trained behavioral scientists who helped facilitate the process. Our nudgeathon process was informed by the 7-stage nudgeathon model (Udall et al., 2019), Indlela’s NUDGE framework (Mandimika et al., 2023), and the UK Behavioral Insights Team’s TESTS framework (The Behavioural Insights Team, 2022).

Over two consecutive days (15–16 March 2023), we led teams through the following activities:

To capitalize on all the insights and ideas that emerged in the nudgeathon, the Indlela team also captured all the brainstormed solutions in a database. Using a hybrid AI-supported (OpenAI, 2023) thematic analysis, we mapped the 602 ideas to 18 categories, which were in turn mapped to the EAST framework (see Table 1). For each category, a stylized exemplar solution was created to illustrate the category.

Our nudgeathon uncovered several high-potential, novel light-touch solutions to some of the challenges facing PrEP delivery targets for gay men and other MSM in South Africa. The robust engagement of implementing partners, practitioners and policy makers ensured that promising solutions could rapidly advance to higher-fidelity prototypes, pilot studies, or directly into practice. Several nudgeathon participants have reported using the outputs for programmatic changes to their PrEP programs in South Africa. We have made the nudgeathon results available online so that these data can serve as a repository for future solutions.

Running a nudgeathon with implementers and policy makers highlighted the critical role that behavioral insights can play in finding appropriate solutions to persistent challenges. Emphasizing the importance of human centered design and incorporating diverse voices in the design process increased the potential for the emerging solutions to be relevant, responsive, and effective. We believe that the nudgeathon is an effective format for engaging with implementers grappling with shared programmatic barriers, and look forward to facilitating additional sessions focused on other barriers in the future.

Ethics & consent

This meeting was programmatic in nature, participation was voluntary, and as no individual level data pertaining to the individual was gathered it was not classified as human subjects research and neither written consent nor ethical approval were required. This is consistent with our institutional ethics guidelines (University of Witwatersrand Human Research Ethics Committee & Boston University Medical Campus Institutional Review Board).

Disclaimer

The views expressed in this article are those of the author(s). Publication in Gates Open Research does not imply endorsement by the Gates Foundation.