Another reality check: the direct costs of providing post-exposure prophylaxis in a population-based programme

Cost-effectiveness of HIV post-exposure prophylaxis in France

OBJECTIVE

To assess the cost-effectiveness of HIV post-exposure prophylaxis (PEP) in France.

METHODS

We used a decision tree to evaluate, from a society's perspective, the cost of PEP per quality-adjusted life-year (QALY) saved. We used 1999-2003 PEP surveillance data and literature-derived data on per event transmission probabilities, PEP efficacy and quality of life with HIV. HIV prevalence and lifetime cost of HIV/AIDS management in the HAART era were derived from French studies. We assumed that mean life expectancy in full health was 65 years among uninfected individuals and that the mean survival time after HIV infection was 22.5 years. The costs of PEP drugs and follow-up were derived from the French public sector. A 3% annual rate was used to discount future costs and effects.

RESULTS

During 1999-2003, PEP was prescribed to 8958 individuals (heterosexual sex: 47.6%; homosexual sex: 28.4%; occupational exposure: 23.4%; drug injection: 0.6%); of those, 2143 were exposed to a known HIV-infected source. PEP was estimated to prevent 7.7 infections and saved 64.5 QALY at a net cost of euro 5.7 million, resulting in an overall cost-effectiveness ratio of euro 88,692 per QALY saved. PEP was cost saving for 4.4% of cases and cost effective (< euro 50,000 per QALY) in a further 11.3% of cases. In contrast, 72 and 52% of prescriptions had a cost-effectiveness ratio exceeding euro 200,000 and euro 2 millions, respectively, per QALY saved.

CONCLUSION

Overall, the French PEP programme is only moderately cost effective. PEP guidelines should be revised to target high-risk exposures better.

Determinants of adherence to non-occupational post HIV exposure prophylaxis

We conducted a study on 140 patients who sought advice at hospital after a non-occupational exposure. The full 28-day course of prophylactic antiretroviral therapy was completed by 109 patients. No HIV contamination was observed. Factors associated with suboptimal adherence were African ethnicity [odds ratio (OR) 13.3, 2.02-87.54] and oral sexual intercourse (OR 8.35, 1.66-41.99). Compliance with prophylactic antiretroviral therapy can be increased by addressing social and psychological barriers to adherence.

Prescribing practices in a population-based HIV postexposure prophylaxis program

OBJECTIVES

To characterize factors associated with being prescribed triple or double postexposure prophylaxis (PEP) against HIV in a population-based program.

METHODS

Individuals potentially exposed to HIV received a 5 day starter kit of either double or triple antiretroviral PEP between April 1999 and November 2000 and did/did not receive the remaining 23 days PEP. Data were collected through dispensation of kits. Logistic regression identified characteristics independently associated with being prescribed triple therapy starter kits and with any 23 day follow-up.

RESULTS

Of 2064 people receiving 5 day PEP [403 (20%) triple and 1661 (80%) double], 590 (29%) received 23 day follow-up. Independently associated with being prescribed triple therapy starter kits were being male [adjusted odds ratio (AOR) 1.38; 95% confidence interval (CI) 1.10-1.74; P = 0.006), occupational mucocutaneous injuries (AOR 1.70; 95% CI, 1.14-2.55; P = 0.010), and community needlesticks (AOR 2.04; 95% CI, 1.54-2.69; P < 0.001). Independently associated with being prescribed the 23 day follow-up were being male (AOR 1.24; 95% CI, 1.00-1.53; P = 0.04), community mucocutaneous incidents (AOR 2.83; 95% CI, 1.41-5.70; P = 0.004), community needlesticks (AOR 1.75; 95% CI, 1.33-2.29; P < 0.001), and having received triple therapy as the starter kit (AOR 2.61; 95% CI, 2.07-3.29; P < 0.001).

CONCLUSIONS

Being prescribed triple therapy starter PEP was associated with being male and with experiencing an occupational mucocutaneous or community needlestick injury. Receiving the remaining 23 days PEP was associated with being male, experiencing a community mucocutaneous or needlestick injury, and triple therapy as the initial 5 day starter PEP.