The cost‐effectiveness of multi‐purpose HIV and pregnancy prevention technologies in South Africa

Abstract

IntroductionA number of antiretroviral HIV prevention products are efficacious in preventing HIV infection. However, the sexual and reproductive health needs of many women extend beyond HIV prevention, and research is ongoing to develop multi‐purpose prevention technologies (MPTs) that offer dual HIV and pregnancy protection. We do not yet know if these products will be an efficient use of constrained health resources. In this paper, we estimate the cost‐effectiveness of combinations of candidate multi‐purpose prevention technologies (MPTs), in South Africa among general population women and female sex workers (FSWs).MethodsWe combined a cost model with a static model of product impact based on incidence data in South Africa to estimate the cost‐effectiveness of five candidate co‐formulated or co‐provided MPTs: oral PrEP, intravaginal ring, injectable ARV, microbicide gel and SILCS diaphragm used in concert with gel. We accounted for the preferences of end‐users by predicting uptake using a discrete choice experiment (DCE). Product availability and protection were systematically varied in five potential rollout scenarios. The impact model estimated the number of infections averted through decreased incidence due to product use over one year. The comparator for each scenario was current levels of male condom use, while a health system perspective was used to estimate discounted lifetime treatment costs averted per HIV infection. Product benefit was estimated in disability‐adjusted life years (DALYs) averted. Benefits from contraception were incorporated through adjusting the uptake of these products based on the DCE and through estimating the costs averted from avoiding unwanted pregnancies. We explore the additional impact of STI protection through increased uptake in a sensitivity analysis.ResultsAt central incidence rates, all single‐ and multi‐purpose scenarios modelled were cost‐effective among FSWs and women aged 16–24, at a governmental willingness‐to‐pay threshold of $1175/DALY averted (range: $214–$810/DALY averted among non‐dominant scenarios), however, none were cost‐effective among women aged 25–49 (minimum $1706/DALY averted). The cost‐effectiveness of products improved with additional protection from pregnancy. Estimates were sensitive to variation in incidence assumptions, but robust to other parameters.ConclusionsTo the best of our knowledge, this is the first study to estimate the cost‐effectiveness of a range of potential MPTs; suggesting that MPTs will be cost‐effective among higher incidence FSWs or young women, but not among lower incidence older women. More work is needed to make attractive MPTs available to potential users who could use them effectively.

Epidemiological impact and cost‐effectiveness of providing long‐acting pre‐exposure prophylaxis to injectable contraceptive users for HIV prevention in South Africa: a modelling study

“…Other studies have modelled the effect of oral or injectable PrEP provided to the general population or to women in an African setting, where especially modelled cost‐effectiveness of methods combining HIV and pregnancy prevention. However, model input parameters and outcome measures often differ between studies, complicating comparison.…”

“…Most studies show PrEP could be cost‐effective in an African setting when provided to individuals at high risk of HIV. Quaife et al shows different scenarios for preventing pregnancies and HIV infections using multi‐purpose prevention technologies in South Africa. They show this would only be cost‐effective for women aged 16 to 24, but not for women aged 25 to 49 because of higher incidence rates for younger women.…”

The effect of HIV prevention products on incentives to supply condomless commercial sex among female sex workers in South Africa

“…Importantly, these results indicate that a degree of substitution from condom‐ to PrEP‐protected sex is a rational response to the use of an effective HIV prevention product, and more work is needed to explore how public health programs can best support FSWs to protect their own sexual and reproductive health. A promising option is the introduction of multipurpose HIV prevention products, co‐formulated or co‐packaged combinations of HIV, STI, and/or contraceptive compounds, which have been estimated to be cost‐effective among FSWs in South Africa (Quaife et al, ). In addition, PrEP use may increase FSW contact with the health system as women collect monthly or three‐monthly prescriptions (Eakle et al, ).…”

How well do discrete choice experiments predict health choices? A systematic review and meta-analysis of external validity

“…Under the assumption that individuals are rational, DCEs can approximate which choice people would make given the option in reality [9,10]. PPA is common outside of health and is increasingly being applied by health economists to predict demand for a range of health-related choices, including HIV prevention products [11], contraceptive services [12], vaccination [13], and migraine treatments [9].…”