Cost-effectiveness of the dual prevention pill for contraception and HIV pre-exposure prophylaxis

Abstract

IntroductionWomen in sub-Saharan Africa (SSA) experience the world's highest rates of both HIV infection and unintended pregnancy. The Dual Prevention Pill (DPP) is a novel multipurpose prevention technology (MPT) that co-formulates HIV pre-exposure prophylaxis (PrEP) and combined hormonal oral contraception into a single daily pill. As a dual indication product, the DPP may be preferred by women facing these overlapping health risks. However, most SSA countries face severe healthcare resource constraints. Research is needed to assess whether, in what populations, and in what use cases the DPP would be cost-effective.MethodsWe augmented an agent-based SSA HIV model with maternal health parameters including unintended pregnancy, abortion, and maternal mortality. Based on a previous market analysis, we assumed a primary DPP user population of current oral contraceptive users ages 25–49, and alternative user populations in different risk groups (age 15–24, sex workers, HIV-serodiscordant couples) and baseline product use profiles (unmet need for contraception, oral PrEP use, condom use). In three geographies (western Kenya, Zimbabwe, South Africa), we estimated HIV infections averted, pregnancies averted, disability-adjusted life-years (DALYs) averted, and the incremental cost-effectiveness ratio (ICER) over a 30-year time horizon, assuming equivalent adherence to the DPP as to oral contraceptives, higher adherence, or lower adherence.ResultsThe DPP is likely to be a cost-effective alternative to oral PrEP among users in need of contraception. Among women not already using PrEP, the DPP is likely to be cost-saving in sex workers and serodiscordant couples. The DPP is unlikely to be cost-effective in oral contraceptive users in the general population. Switching from oral contraception to the DPP could be net harmful in some settings and populations if it were to substantially reduces adherence to oral contraception. Results were robust to a range of time horizons or discount rates.ConclusionThe DPP has the potential to be cost-effective and cost-saving in populations at substantial HIV risk. Outcomes are sensitive to adherence, implying that effective counseling and decision-making tools for users considering the DPP will be essential. More research is needed to understand real-life adherence patterns and ensure health benefits achieved from contraception alone are not lost.

Program impact and potential pitfalls of multi-purpose technologies (MPTs) for HIV prevention and contraception

“…In both scenarios above–either attracting new users or expanding coverage to those with unmet need for a second indication–additional benefit is realized so long as the added coverage occurs among women at high risk for the outcomes as suggested by cost effectiveness modeling. Analyses scaling a MPT for HIV and pregnancy found pregnancy prevention would be cost effective if rolled out to women at high risk of HIV (e.g., serodiscordant couples, AGYW or female sex workers) but not to a general population of women ( 14 , 15 ). Notable was that a MPT for HIV and pregnancy was cost effective among populations at high risk for HIV even with HIV method efficacy ranging from 45% to 75% ( 15 ).…”

“…Notable was that a MPT for HIV and pregnancy was cost effective among populations at high risk for HIV even with HIV method efficacy ranging from 45% to 75% ( 15 ). Modeling of the dual prevention pill (DPP) found that scaling the DPP was sensitive to both risk of HIV in the population and adherence (e.g., use-effectiveness), where if adherence was low, the health risks from unintended pregnancy could outweigh the health benefit of HIV prevention ( 14 ).…”

“…However, there are potential pitfalls for a MPT highly dependent on adherence, such as the daily oral DPP. As per DPP cost-effectiveness modeling, expanded population coverage achieved could be outweighed by poor adherence and lowered use-effectiveness, as daily pill taking may be more challenging than using longer-acting methods ( 14 ). Since the average probability of conception is higher than HIV transmission, poor adherence to the daily oral DPP could be offset by unplanned pregnancy without necessarily increasing HIV protection.…”