Cost and cost-effectiveness of an HIV pre-exposure prophylaxis (PrEP) programme for high-risk men who have sex with men in England: results of a static decision analytical model

Abstract

Background The effi cacy and eff ectiveness of pre-exposure prophylaxis (PrEP) for preventing HIV infection acquisition by high-risk men who have sex with men (MSM) is established. We estimated the cost and cost-eff ectiveness of a proposed daily oral PrEP programme covering 10 000 high-risk MSM attending genitourinary medicine clinics in England. Methods From the perspective of public providers, a static decision analytical model was used to investigate lifetime HIV infections, treatment costs, and quality-adjusted-life-year (QALY) losses associated with daily PrEP given for 1 year, beginning in 2016, compared with no intervention. A cohort of MSM who were not known to be HIV positive at their fi rst attendance in 2012 and had tested HIV negative between 42 and 365 days previously was identifi ed. These men were followed up from the date of their earliest negative HIV test in 2012 for up to 1 year either until they seroconverted or until their last attendance. HIV incidence was calculated as the number of seroconversions (new HIV diagnoses) per 100 person-years. Data sources including genitourinary medicine clinic activity data were used to estimate HIV incidence in year 1 and thereafter. Costs were updated to 2013-14 values and both future costs and QALYs were discounted at 3•5%. Budgetary impact was undiscounted. Findings At 86% eff ectiveness, delivery of PrEP to 10 000 high-risk MSM in the fi rst year (target population with an HIV incidence of 2•4 per 100 person-years in year 1) resulted in 178 fewer lifetime HIV infections, 28 delayed infections, and an incremental cost-eff ectiveness ratio (ICER) of £26 300, compared with no PrEP. More conservative assumptions of 64% PrEP eff ectiveness gave an ICER of £54 500, compared with no PrEP. ICER was highly sensitive to year 1 HIV incidence (eg, with HIV incidence of 3•3 per 100 person-years and at 86% PrEP eff ectiveness, ICER was £4170), PrEP eff ectiveness, PrEP drug costs, and potential changes in antiretroviral treatment cost upon patent expiry. An investment of £54 million in year 1 breaks even anywhere from year 42 (86% PrEP eff ectiveness) to beyond year 61 (64% PrEP eff ectiveness). Interpretation The model shows that the estimated cost-eff ectiveness of PrEP is very sensitive to key variables (eg, year 1 HIV incidence and patient adherence), about which there is much uncertainty, especially if programme scale-up occurs. A substantial reduction in the price of antiretroviral drugs, when used for PrEP, is needed to give the necessary assurance of cost-eff ectiveness, and for an aff ordable public health programme of suffi cient size. Funding None. Contributors KJO, AJvH, and ONG designed the analysis and developed the methodology. SD performed analysis of genitourinary medicine clinic activity data and provided HIV incidence estimates. KJO performed the cost-eff ectiveness analysis, which was appraised by AJvH. KJO and ONG drafted the abstract. SD, MD, AN, and AJvH commented on the abstract.

2016 United Kingdom national guideline on the sexual health care of men who have sex with men

“…managing the duration of PrEP use and the use of event-based PrEP and obtaining antiretrovirals at a reduced price on the patent expiry of Truvada in 2018 will be critical to ensuring cost-effective implementation (380,381).…”

BHIVA/BASHH guidelines on the use of HIV pre–exposure prophylaxis (PrEP) 2018

“…92% , 10–90% , 90% ). More recent studies considered higher levels of efficacy (80–86%) consistent with the new trials.…”

“…Nine cost‐effectiveness studies were based on dynamic models , four used a static model , two used number needed to treat, respectively based on the iPrEx trial and the ANRS IPERGAY trial to estimate cost‐effectiveness , and for one it was not clear (only available as an abstract) .…”

“…The identified studies considered the MSM population in the US generally or in specific cities (New York City and Los Angeles County , Canada , Australia and in particular New South Wales , the Netherlands , France and the UK ). The settings to which they refer are characterised by different HIV incidence in the MSM population, and different costs for treatment of people living with HIV and for PrEP, and these factors have been found to be crucial in determining the cost‐effectiveness of this prevention intervention.…”

“…Ouellet et al investigated the use of daily dosing for on‐demand PrEP, the most expensive on‐demand scenario . All of the peer‐reviewed papers were thought to be of high/acceptable quality using the SIGN checklist (http://www.sign.ac.uk/checklists-and-notes.html); it was not possible to assess it for the conference abstracts and the correspondence .…”