Costs and Cost-Effectiveness of Biomedical, Non-Surgical HIV Prevention Interventions: A Systematic Literature Review

Abstract

Background Considerable evidence on the costs and cost-effectiveness of biomedical, non-surgical interventions to prevent human immunodeficiency virus (HIV) transmission has been generated over the last decade. This study aims to synthesize findings and identify remaining knowledge gaps to suggest future research priorities. Methods A systematic literature review was carried out in August 2020 using the MEDLINE, Embase, Global Health and EconLit databases to retrieve economic evaluations and costing studies of oral pre-exposure prophylaxis (PrEP), injectable long-acting PrEP, vaginal microbicide rings and gels, HIV vaccines and broadly neutralizing antibodies. Studies reporting costs from the provider or societal perspective were included in the analysis. Those reporting on behavioural methods of prevention, condoms and surgical approaches (voluntary medical male circumcision) were excluded. The quality of reporting of the included studies was assessed using published checklists. Results We identified 3007 citations, of which 87 studies were retained. Most were set in low-and middle-income countries (LMICs; n = 53) and focused on the costs and/or cost-effectiveness of oral PrEP regimens (n = 70). Model-based economic evaluations were the most frequent study design; only two trial-based cost-effectiveness analyses and nine costing studies were found. Less than half of the studies provided practical details on how the intervention would be delivered by the health system, and only three of these, all in LMICs, explicitly focused on service integration and its implication for delivery costs. 'Real-world' programme delivery mechanisms and costs of intervention delivery were rarely considered. PrEP technologies were generally found to be cost-effective only when targeting high-risk subpopulations. Single-dose HIV vaccines are expected to be cost-effective for all groups despite substantial uncertainty around pricing. Conclusions A lack of primary, detailed and updated cost data, including above-service level costs, from a variety of settings makes it difficult to evaluate the cost-effectiveness of specific delivery modes at scale, or to evaluate strategies for services integration. Closing this evidence gap around real-world implementation is vital, not least because the strategies targeting high-risk groups that are recommended by PrEP models may incur substantially higher costs and be of limited practical feasibility in some settings.

Implementation and resource needs for long‐acting PrEP in low‐ and middle‐income countries: a scoping review

“…We observed that most studies did not meet GHCC criteria, including variable cost and cost‐effectiveness outcomes and units of measure. The lower quality, inconsistencies, and lack of transparency in cost and cost‐effectiveness studies have been raised by others, but to our knowledge, this is the first study to examine the cost and cost‐effectiveness literature against real‐world operational plans and assess implementation inputs and activities with such specificity [ 32 ].…”

“…and Giddings et al. [ 32 , 33 ]. We chose 2010 because clinical trials for daily oral PrEP were underway, and many countries were already considering ways to incorporate PrEP into national HIV plans, pending proven safety and efficacy.…”

“…Co‐authors (DC, SF, CJH, NT, JW and KK) extracted relevant data from the included studies into REDCap [ 34 ]. Co‐authors (FB, FTP and STR) conducted an independent review to supplement this review's findings [ 32 , 35 ].…”

“…The wide variation in cost outcomes poses a synthesis challenge identified in this review and previously [32]. Standardized costing instruments should be created, including guidance on costing attributes for inclusion and the process of costing PrEP.…”

“…average or incremental) or economic evaluation outcomes, such as cost-effectiveness, cost-benefit, or cost-utility; (4) was conducted in any LMIC (classified using World Bank categorizations [31]); and (5) was published in English. We compared our final study sample with other recent reviews on the modelling and cost-effectiveness of biomedical HIV prevention by Bozzani et al and Giddings et al [32,33]. We chose 2010 because clinical trials for daily oral PrEP were underway, and many countries were already considering ways to incorporate PrEP into national HIV plans, pending proven safety and efficacy.…”