Evaluating the impact of prioritization of antiretroviral pre-exposure prophylaxis in New York

Abstract

Objective To compare the value and effectiveness of different prioritization strategies of pre-exposure prophylaxis (PrEP) in New York City (NYC). Design Mathematical modeling utilized as clinical trial is not feasible. Methods Using a model accounting for both sexual and parenteral transmission of HIV we compare different prioritization strategies (PPS) for PrEP to two scenarios—no PrEP and PrEP for all susceptible at-risk individuals. The PPS included PrEP for all MSM, only high-risk MSM, high-risk heterosexuals, and injection drug users, and all combinations of these four strategies. Outcomes included HIV infections averted, and incremental cost effectiveness (per-infection averted) ratios. Initial assumptions regarding PrEP included a 44% reduction in HIV transmission, 50% uptake in the prioritized population and an annual cost per person of $9,762. Sensitivity analyses on key parameters were conducted. Results Prioritization to all MSM results in a 19% reduction in new HIV infections. Compared to PrEP for all persons at-risk this PPS retains 79% of the preventative effect at 15% of the total cost. PrEP prioritized to only high-risk MSM results in a reduction in new HIV infections of 15%. This PPS retains 60% of the preventative effect at 6% of the total cost. There are diminishing returns when PrEP utilization is expanded beyond this group. Conclusions PrEP implementation is relatively cost-inefficient under our initial assumptions. Our results suggest that PrEP should first be promoted among MSM who are at particularly high-risk of HIV acquisition. Further expansion beyond this group may be cost-effective, but is unlikely to be cost-saving.

A SWOT Analysis of the Updated National HIV/AIDS Strategy for the U.S., 2015–2020

“…Therefore, to implement PrEP for persons who might benefit one must delve into substantial detail about how to ensure coverage by public sector programs, as well as how to involve the private sector in reducing the drug price and encouraging insurance companies to guarantee coverage. Further, estimates of the cost-effectiveness of this investment would be useful as the published literature on the cost-effectiveness of PrEP varies from study to study largely depending on how PrEP is targeted in its implementation (and cost-effectiveness is key for achieving the maximum public health benefit for a given level of resource) [14][15][16]. Therefore, PrEP is a critical new tool in HIV prevention, but identifying payment strategies and ways to best target PrEP services are key to its most impactful implementation and should be included in the federal action plan to the updated NHAS.…”

Likely impact of pre-exposure prophylaxis on HIV epidemics among men who have sex with men

“…For instance, the latest study, published in 2016, looked at PrEP coverage of 25%, 50%, 75% and 100% in comparison with no PrEP use. 25 As to adherence, Kessler et al 24 and Schneider et al 26 considered adherence of 63% and 75%, respectively, while Carnegie et al used adherence cut-offs of zero, two and four pills per week, with a corresponding per-contact risk reduction of 0%, 75% and 90%, respectively.…”

“…Among the selected six studies, three [22][23][24] focused on modelling the impact of PrEP on HIV diagnoses in the US (including one study that looked at the US and Peru MSM 22 ), and the other three studies presented models for the UK, 25 Australia 26 and South Korea. 27 As to the methods, two studies used a stochastic model, which estimated probability distributions of HIV diagnoses by allowing for random variation in one or more input indicators over time; 22,26 three studies applied deterministic models; [23][24][25] and one study described their method as a mathematical simulation model.…”

“…27 As to the methods, two studies used a stochastic model, which estimated probability distributions of HIV diagnoses by allowing for random variation in one or more input indicators over time; 22,26 three studies applied deterministic models; [23][24][25] and one study described their method as a mathematical simulation model. 27 All six studies were selected because they modelled HIV diagnoses over time, but three of the studies also 23 and 2014 24,27 ), included a PrEP efficacy of 44% in their models. This was the finding of the intent-to-treat analysis from the iPrEx study (also known as the Chemoprophylaxis for HIV Prevention in Men trial or the PrEP Initiative).…”

“…Interestingly, the US studies included two very differing assumptions about annual texting probability: 31% in Kessler et al 24 and 67% in Juusola et al 23 …”