The Cost-Effectiveness of Preexposure Prophylaxis for HIV Prevention in the United States in Men Who Have Sex With Men

Abstract

Background In a recent randomized controlled trial, daily oral preexposure chemoprophylaxis (PrEP) was shown to be effective for HIV prevention in men who have sex with men (MSM). The United States Centers for Disease Control and Prevention (CDC) recently provided interim guidance for PrEP use among MSM who are at high risk for acquiring HIV. Previous studies failed to reach a consistent estimate of its cost-effectiveness. Objective To estimate the effectiveness and cost-effectiveness of PrEP in MSM in the United States. Design Dynamic model of HIV transmission and progression combined with a detailed economic analysis. Data Sources Published literature. Target Population MSM aged 13–64 in the United States. Time Horizon Lifetime. Perspective Societal. Interventions We evaluated PrEP for the general MSM population and for high-risk MSM. We assumed that PrEP reduces infection risk by 44%, based on clinical trial results. Outcome Measures New HIV infections, discounted quality-adjusted life-years (QALYs) and costs, and incremental cost-effectiveness ratios. Results of Base-Case Analysis If PrEP is initiated in 20% of MSM in the United States, we estimate a 13% reduction in new HIV infections and a gain of 550,166 QALYs over 20 years at a cost of $172,091/QALY gained. Initiating PrEP in a larger proportion of MSM averts more infections but at increasing cost per QALY gained ($216,480/QALY gained when 100% of MSM receive PrEP). Using PrEP only in high-risk MSM can improve its cost-effectiveness. PrEP costs approximately $50,000/QALY gained for MSM with 5 annual partners on average. PrEP for all high-risk MSM for 20 years leads to $75 billion in healthcare-related costs incremental to the status quo and costs $600,000 per HIV infection averted, compared with incremental costs of $95 billion and $2 million per infection averted for 20% coverage of all MSM. Results of Sensitivity Analysis PrEP use in the general MSM population costs less than $100,000/QALY gained if the daily cost of antiretroviral drugs for PrEP is less than $15 or if PrEP efficacy is greater than 75%. Limitation When examining PrEP use in high-risk MSM, we did not model mixing between low- and high-risk MSM because of lack of data on mixing patterns. Conclusion Use of PrEP for HIV prevention in the general MSM population could prevent a substantial number of HIV infections but is expensive. PrEP use in high-risk MSM compares favorably to other interventions considered cost-effective, but could result in annual expenditures on PrEP of over $4 billion.

Potential Cost-Effectiveness of Pre-exposure Prophylaxis Combined with HIV Vaccines in the United States

“…The PrEP-alone cost-effectiveness findings align with Juusola et al, who estimated PrEP for all MSM costs $216,480 per QALY gained (differing 5% from our ICER for this population) [19]. Similarly, PrEP for injection drug users in the US was estimated by Bernard et al to cost $253,000 per QALY gained [20].…”

“…Previous economic evaluations have separately examined the cost-effectiveness of PrEP or HIV vaccines in the US, but none have modeled the potential outcomes when combining these products [18][19][20][21][22][23], as shown in a recent review of HIV vaccine cost-effectiveness studies [24]. For treatment of HIV, Truvada® is highly cost-effective when used in combination with other drugs, but the costeffectiveness estimates for prevention are mixed in reviews [21,25,26].…”

High Interest in Preexposure Prophylaxis Among Men Who Have Sex With Men at Risk for HIV Infection

“…Modeling studies suggest that the uptake of PrEP among those at highest risk of HIV will maximize the cost-effectiveness 15,45 and public health impact of PrEP 46 . The cohort of participants who enrolled in the Demo Project reported high rates of recreational drug use, condomless receptive anal sex, and had a high prevalence of early syphilis or rectal infections, all factors strongly associated with HIV acquisition 42,47-49 .…”

“…Modeling studies suggest PrEP could substantially reduce HIV incidence among MSM in the US, and may be cost effective if targeted to the highest risk populations 13-15 . However, little is known about levels of interest and characteristics of individuals who elect to take PrEP in clinical settings.…”

“…An analysis of pharmacy claims found that between January 2012 and September 2013, only 2319 people filled prescriptions for FTC/TDF PrEP in the US and almost half were women 16 . Several factors, including perceived low demand for PrEP 17-19 , inadequate access to insurance or healthcare 20 , lack of provider knowledge or willingness to prescribe PrEP 21-24 , and concerns about adherence 25 , HIV resistance 26 , risk compensation 27 , and cost 20,28 may explain why there has not been rapid dissemination of this innovation. Demonstration projects have been recommended to address implementation issues and help determine if appropriate and how best to scale-up PrEP 29,30 .…”