Assessing the Cost Effectiveness of Pre-Exposure Prophylaxis for HIV Prevention in the US

Abstract

About 50,000 people are infected with HIV in the US each year and this number has remained virtually the same for the past decade. Yet, in the last few years, evidence from several multinational randomized clinical trials has shown that the provision of antiretroviral drug to uninfected persons (i.e. pre-exposure prophylaxis) reduces the incidence of HIV by about 50 %. However, evidence from cost-effectiveness studies conducted in the US yield widely varying estimates of the cost per quality-adjusted life-year (QALY) gained, and this variation reflects the substantial uncertainty surrounding the determinants of HIV transmission (e.g. adherence rates to prophylactic medications, the average number of sexual partners, the number and types of sexual acts, the viral load of infected partners, and the proportion of contacts where condoms are used), as well as different approaches to translating a reduction in HIV cases into an estimate of the increase in the number of QALYs. Key Points for Decision Makers• Pre-exposure prophylaxis programs have the potential to lower the cost of the HIV epidemic in the US.• Studies of the cost effectiveness of pre-exposure prophylaxis programs should explain and justify assumptions underlying their economic model of HIV transmission.• It is important to recognize that different assumptions about the patterns of sexual behaviour of men who have sex with men may produce very different estimates of the cost effectiveness of pre-exposure prophylaxis programs.

An action agenda for HIV and sex workers

“…Drug costs will be a major determinant with Truvada costing as much as $10,000 per year in some countries. 58 Additionally, local variation in HIV, condom use and patterns of sex work may dramatically affect the effectiveness of microbicides 59 and oral PrEP. 60 …”

What do we know about the cost–effectiveness of HIV preexposure prophylaxis, and is it affordable?

“…A number of literature reviews on the cost-effectiveness of PrEP have been performed: some specific to the US (22) and some more general (23). A previous literature review of cost-effectiveness studies in the US (all in MSM), concluded that there was substantial variation in the cost per QALY gained.…”

The Cost-Effectiveness of HIV/STI Prevention in High-Income Countries with Concentrated Epidemic Settings: A Scoping Review

“…For instance, a French study found additional benefits associated with the introduction of PrEP, such as the treatment of other diseases and a reduction in secondary infections [ 141 ]. In sum, even though the cost-effectiveness results vary, it appears that PrEP can be a cost-effective addition to other HIV prevention programmes since it has the potential to prevent a substantial number of HIV infections and thus to mitigate the HIV epidemic [ 142 ]. Existing evidence suggests that the enormous upfront costs in providing PrEP should result in substantial economic benefits in the long term [ 143 ].…”