Assessing the cost effectiveness of pre-exposure prophylaxis for HIV prevention in the US

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

The purpose of this scoping review is to establish the state of the art on economic evaluations in the field of HIV/STI prevention in high-income countries with concentrated epidemic settings and to assess what we know about the cost-effectiveness of different measures. We reviewed economic evaluations of HIV/STI prevention measures published in the Web of Science and Cost-Effectiveness Registry databases. We included a total of 157 studies focusing on structural, behavioural, and biomedical interventions, covering a variety of contexts, target populations and approaches. The majority of studies are based on mathematical modelling and demonstrate that the preventive measures under scrutiny are cost-effective. Interventions targeted at high-risk populations yield the most favourable results. The generalisability and transferability of the study results are limited due to the heterogeneity of the populations, settings and methods involved. Furthermore, the results depend heavily on modelling assumptions. Since evidence is unequally distributed, we discuss implications for future research.

Costs and benefits of on-demand HIV preexposure prophylaxis in MSM

OBJECTIVES

We undertook the economic evaluation of the double-blind randomized ANRS-IPERGAY trial, which showed the efficacy of on-demand preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate (TDF)-emtricitabine (FTC) in preventing HIV infection among high-risk MSM.

DESIGN AND METHODS

The economic evaluation was prospective. Counseling, drugs (TDF-FTC at &OV0556;500.88 for 30 tablets), tests, visits, and hospital admissions were valued based on in-trial use. The cost of on-demand PrEP/HIV infection averted was compared with the yearly and lifetime costs of HIV infection in France in a cost and benefits analysis.

RESULTS

The yearly number of participants needed to treat to prevent one HIV infection was 17.6 (95% confidence interval = 10.7-49.9). The annual cost of counseling was &OV0556;690/participant. The total 1-year costs of PrEP were &OV0556;4271/participant, of which &OV0556;3129 (73%) were drug costs corresponding to 15 tablets of TDF-FTC/month. The yearly cost of on-demand PrEP to avoid one infection was &OV0556;75 258. Using TDF-FTC generic (&OV0556;179.9/30 tablets) reduced the 1-year costs of on-demand PrEP to &OV0556;2271/participant and &OV0556;39 970/infection averted, respectively. Using TDF-FTC at international market discounted prices (&OV0556;60/30 tablets) reduced the costs to &OV0556;1517/participant and the cost to &OV0556;26 787/infection averted, comparable with the yearly treatment cost of HIV infection in France. On-demand PrEP was found to be cost saving in France if the duration of exposure was less than 7.5 years at current drug price and 13 years at generic price.

CONCLUSION

On-demand PrEP in high-risk MSM with TDF-FTC can be considered cost saving. Other benefits include the treatments of other diseases and reductions in secondary infections.

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

PURPOSE OF REVIEW

The WHO recommends preexposure prophylaxis (PrEP) in populations at substantial risk of HIV. Despite a number of randomized controlled trials demonstrating its efficacy, and several ongoing implementation projects, PrEP is currently only available in a few countries. Modelling studies can provide useful insights into the long-term impact of introducing PrEP in different subgroups of the population. The review summarizes studies that either evaluated the cost-effectiveness or the cost of introducing PrEP, focusing on seven published in the last year.

RECENT FINDINGS

These studies used a number of different types of models and investigated the introduction of PrEP in different settings. Among men having sex with men (MSM) in North America, PrEP ranged from being cost-saving (while benefiting population health) to costing US $160,000/quality-adjusted life-year gained. Among heterosexual sero-different couples, it varied from around US $5000 to US $10,000/disability-adjusted life-year averted, when PrEP was used until 6 or 12 months after the HIV-positive partner had initiated antiretroviral therapy (ART) in, respectively, Uganda and South Africa.

SUMMARY

Future cost-effectiveness studies of PrEP should consider the HIV incidence, the level of uptake, the effect of its introduction on alternative prevention approaches, and the budget impact of rolling it out.

The preexposure prophylaxis revolution: from clinical trials to routine practice: implementation view from the USA

PURPOSE OF REVIEW

This article describes the use of tenofovir/emtricitabine (Truvada) as prevention for exposure to HIV [preexposure prophylaxis (PrEP)] infection in the USA. The use of PrEP and the challenges of implementation are very instructive as other countries adopt this intervention and it becomes a fundamental part of worldwide efforts for HIV prevention and much can be learned from the first 3 years in the USA.

RECENT FINDINGS

Randomized trials and demonstration projects have shown the benefits of PrEP for men and women who are at risk for HIV. Numerous studies have showed that the level of prevention is excellent when the drug is taken at least four times weekly, once adequate levels are obtained. However, adherence remains a critical issue as well as tailoring delivery models for specific populations. Six recent studies are discussed, that support excellent efficacy and significantly support PrEP as a means of prevention. These projects have shown high acceptance of PrEP with excellent adherence by individuals demonstrated by those at risk remaining free of HIV over extended periods of time.

SUMMARY

The USA faces three significant challenges in scaling up PrEP. The first challenge in implementation in the USA is to get individuals to recognize the actual risks that their behaviors represent and to engage with providers to address these issues. The second challenge is getting a population of providers to recognize the exact same issues and offer PrEP in a compassionate, nonjudgmental fashion. The third challenge is identifying the set of providers and locations to scale-up the response in a timely, cost-effective fashion.

Comparing the impact of increasing condom use or HIV pre-exposure prophylaxis (PrEP) use among female sex workers

In many settings, interventions targeting female sex workers (FSWs) could significantly reduce the overall transmission of HIV. To understand the role HIV pre-exposure prophylaxis (PrEP) could play in controlling HIV transmission amongst FSWs, it is important to understand how its impact compares with scaling-up condom use-one of the proven HIV prevention strategies for FSWs. It is important to remember that condoms also have other benefits such as reducing the incidence of sexually transmitted infections and preventing pregnancy. A dynamic deterministic model of HIV transmission amongst FSWs, their clients and other male partners (termed 'pimps') was used to compare the protection provided by PrEP for HIV-negative FSWs with FSWs increasing their condom use with clients and/or pimps. For different HIV prevalence scenarios, levels of pimp interaction, and baseline condom use, we estimated the coverage of PrEP that gives the same reduction in endemic FSW HIV prevalence or HIV infections averted as different increases in condom use. To achieve the same impact on FSW HIV prevalence as increasing condom use by 1%, the coverage of PrEP has to increase by >2%. The relative impact of PrEP increases for scenarios where pimps contribute to HIV transmission, but not greatly, and decreases with higher baseline condom use. In terms of HIV infections averted over 10 years, the relative impact of PrEP compared to condoms was reduced, with a >3% increase in PrEP coverage achieving the same impact as a 1% increase in condom use. Condom promotion interventions should remain the mainstay HIV prevention strategy for FSWs, with PrEP only being implemented once condom interventions have been maximised or to fill prevention gaps where condoms cannot be used.

The promises and challenges of pre-exposure prophylaxis as part of the emerging paradigm of combination HIV prevention

INTRODUCTION

Towards the end of the twentieth century, significant success was achieved in reducing incidence in several global HIV epidemics through ongoing prevention strategies. However, further progress in risk reduction was uncertain. For one thing, it was clear that social vulnerability had to be addressed, through research on interventions addressing health systems and other structural barriers. As soon as antiretroviral treatment became available, researchers started to conceive that antiretrovirals might play a role in decreasing either susceptibility in uninfected people or infectiousness among people living with HIV. In this paper we focus on the origin, present status, and potential contribution of pre-exposure prophylaxis (PrEP) within the combination HIV prevention framework.

DISCUSSION

After a phase of controversy, PrEP efficacy trials took off. By 2015, daily oral PrEP, using tenofovir alone or in combination with emtricitabine, has been proven efficacious, though efficacy seems heavily contingent upon adherence to pill uptake. Initial demonstration projects after release of efficacy results have shown that PrEP can be implemented in real settings and adherence can be high, leading to high effectiveness. Despite its substantial potential, beliefs persist about unfeasibility in real-life settings due to stigma, cost, adherence, and potential risk compensation barriers.

CONCLUSIONS

The strategic synergy of behavioural change communication, biomedical strategies (including PrEP), and structural programmes is providing the basis for the combination HIV prevention framework. If PrEP is to ever become a key component of that framework, several negative beliefs must be confronted based on emerging evidence; moreover, research gaps regarding PrEP implementation must be filled, and appropriate prioritization strategies must be set up. Those challenges are significant, proportional to the impact that PrEP implementation may have in the global response to HIV.

An action agenda for HIV and sex workers

The women, men, and transgender people who sell sex globally have disproportionate risks and burdens of HIV in countries of low, middle, and high income, and in concentrated and generalised epidemic contexts. The greatest HIV burdens continue to be in African female sex workers. Worldwide, sex workers still face reduced access to needed HIV prevention, treatment, and care services. Legal environments, policies, police practices, absence of funding for research and HIV programmes, human rights violations, and stigma and discrimination continue to challenge sex workers' abilities to protect themselves, their families, and their sexual partners from HIV. These realities must change to realise the benefits of advances in HIV prevention and treatment and to achieve global control of the HIV pandemic. Effective combination prevention and treatment approaches are feasible, can be tailored for cultural competence, can be cost-saving, and can help to address the unmet needs of sex workers and their communities in ways that uphold their human rights. To address HIV in sex workers will need sustained community engagement and empowerment, continued research, political will, structural and policy reform, and innovative programmes. But such actions can and must be achieved for sex worker communities everywhere.

Pre-exposure prophylaxis for human immunodeficiency virus: the past, present, and future

This article presents an overview of pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention. The authors describe the past animal and human research that has been conducted that informs our current understanding of PrEP; summarize ongoing research in the area, including describing new regimens and delivery mechanisms being studied for PrEP; and highlight key issues that must be addressed in order to implement and optimize the use of this HIV prevention tool.

Should patients with ocular genetic disorders have genetic testing?

PURPOSE OF REVIEW

To discuss the risks, benefits and value of genetic testing for ocular genetic disease.

RECENT FINDINGS

Testing for ocular genetics diseases is becoming more available and successful gene therapy is being reported. Clinicians must prepare for this trend by considering diagnostic genetic testing for their patients.

SUMMARY

As advances continually occur in genetic testing for ocular genetic disorders, clinicians must develop an understanding of the potential risks and benefits for their patients.