Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis

Abstract

BackgroundThe risks of HIV transmission associated with the opioid epidemic make cost-effective programs for people who inject drugs (PWID) a public health priority. Some of these programs have benefits beyond prevention of HIV—a critical consideration given that injection drug use is increasing across most United States demographic groups. To identify high-value HIV prevention program portfolios for US PWID, we consider combinations of four interventions with demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure prophylaxis (PrEP).Methods and findingsWe adapted an empirically calibrated dynamic compartmental model and used it to assess the discounted costs (in 2015 US dollars), health outcomes (HIV infections averted, change in HIV prevalence, and discounted quality-adjusted life years [QALYs]), and incremental cost-effectiveness ratios (ICERs) of the four prevention programs, considered singly and in combination over a 20-y time horizon. We obtained epidemiologic, economic, and health utility parameter estimates from the literature, previously published models, and expert opinion. We estimate that expansions of OAT, NSPs, and Test & Treat implemented singly up to 50% coverage levels can be cost-effective relative to the next highest coverage level (low, medium, and high at 40%, 45%, and 50%, respectively) and that OAT, which we assume to have immediate and direct health benefits for the individual, has the potential to be the highest value investment, even under scenarios where it prevents fewer infections than other programs. Although a model-based analysis can provide only estimates of health outcomes, we project that, over 20 y, 50% coverage with OAT could avert up to 22,000 (95% CI: 5,200, 46,000) infections and cost US$18,000 (95% CI: US$14,000, US$24,000) per QALY gained, 50% NSP coverage could avert up to 35,000 (95% CI: 8,900, 43,000) infections and cost US$25,000 (95% CI: US$7,000, US$76,000) per QALY gained, 50% Test & Treat coverage could avert up to 6,700 (95% CI: 1,200, 16,000) infections and cost US$27,000 (95% CI: US$15,000, US$48,000) per QALY gained, and 50% PrEP coverage could avert up to 37,000 (22,000, 58,000) infections and cost US$300,000 (95% CI: US$162,000, US$667,000) per QALY gained. When coverage expansions are allowed to include combined investment with other programs and are compared to the next best intervention, the model projects that scaling OAT coverage up to 50%, then scaling NSP coverage to 50%, then scaling Test & Treat coverage to 50% can be cost-effective, with each coverage expansion having the potential to cost less than US$50,000 per QALY gained relative to the next best portfolio. In probabilistic sensitivity analyses, 59% of portfolios prioritized the addition of OAT and 41% prioritized the addition of NSPs, while PrEP was not likely to be a priority nor a cost-effective addition. Our findings are intended to be illustrative, as data on achievable coverage are limite...

Integrated Models of Care for Individuals with Opioid Use Disorder: How Do We Prevent HIV and HCV?

“…SSPs provide non-judgmental, free, accessible testing and care services to PWID who often do not have contact with medical services or who shun medical care because of stigma and prior poor treatment [ 53 ]. A recent study found that 50% SSP coverage within the USA would be cost-effective and avert up to 35,000 HIV infections over 20 years [ 54 ]. For maximal impact, SSPs must provide a robust array of health services [ 55 – 57 ], including HIV testing linked to both primary (e.g., sterile equipment, addiction treatment, PrEP) and secondary HIV prevention (e.g., TasP), and HCV testing with linkage to parallel services.…”

Cost and cost‐effectiveness analysis of pre‐exposure prophylaxis among men who have sex with men in two hospitals in Thailand

“…We searched PubMed from 1 January 2013 to 11 October 2017 with the terms "HIV" AND ("PrEP" OR "PrEP") AND ("cost" OR "costeffectiveness") with the goal of identifying any new studies that have appeared since the 2013 meta-analysis of PrEP cost-effectiveness modelling studies [32]. The search retrieved 149 abstracts, of which 21 provided country-specific estimates of the cost-effectiveness of various PrEP implementation strategies [6,8,9,[33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49]. This study is not only the first to provide data and evidence on the costs and cost-effectiveness of providing oral PrEP to MSM in Thailand, but is also the first such study from the Asia-Pacific region.…”

Structural sensitivity in HIV modeling: A case study of vaccination

“…Aside from the characteristics detailed above, individuals are homogenous and cannot be distinguished from one another in the model. Details of transmission calculations and model equations can be found in the Appendix and in the appendix of two previously published analyses ( Bernard et al., 2017 , Bernard et al., 2016 ).…”