Maximising HIV prevention by balancing the opportunities of today with the promises of tomorrow: a modelling study

Abstract

SummaryBackgroundMany ways of preventing HIV infection have been proposed and more are being developed. We sought to construct a strategic approach to HIV prevention that would use limited resources to achieve the greatest possible prevention impact through the use of interventions available today and in the coming years.MethodsWe developed a deterministic compartmental model of heterosexual HIV transmission in South Africa and formed assumptions about the costs and effects of a range of interventions, encompassing the further scale-up of existing interventions (promoting condom use, male circumcision, early antiretroviral therapy [ART] initiation for all [including increased HIV testing and counselling activities], and oral pre-exposure prophylaxis [PrEP]), the introduction of new interventions in the medium term (offering intravaginal rings, long-acting injectable antiretroviral drugs) and long term (vaccine, broadly neutralising antibodies [bNAbs]). We examined how available resources could be allocated across these interventions to achieve maximum impact, and assessed how this would be affected by the failure of the interventions to be developed or scaled up.FindingsIf all interventions are available, the optimum mix would place great emphasis on the following: scale-up of male circumcision and early ART initiation with outreach testing, as these are available immediately and assumed to be low cost and highly efficacious; intravaginal rings targeted to sex workers; and vaccines, as these can achieve a large effect if scaled up even if imperfectly efficacious. The optimum mix would rely less on longer term developments, such as long-acting antiretroviral drugs and bNAbs, unless the costs of these reduced. However, if impossible to scale up existing interventions to the extent assumed, emphasis on oral PrEP, intravaginal rings, and long-acting antiretroviral drugs would increase. The long-term effect on the epidemic is most affected by scale-up of existing interventions and the successful development of a vaccine.InterpretationWith current information, a strategic approach in which limited resources are used to maximise prevention impact would focus on strengthening the scale-up of existing interventions, while pursuing a workable vaccine and developing other approaches that can be used if further scale-up of existing interventions is limited.FundingBill & Melinda Gates Foundation.

Dapivirine vaginal ring for HIV prevention: modelling health outcomes, drug resistance and cost‐effectiveness

“…Contrastingly, FSW‐PrEP decreased HIV expenditures overall. Thus, FSW‐PrEP was cost‐saving over both intervention and lifetime horizons of PrEP scenarios, in qualitative agreement with previous modelling of oral, injectable and vaginal ring PrEP . Meanwhile, incidence‐based PrEP was more cost‐effective than age‐based or unprioritized PrEP.…”

Comparative assessment of five trials of universal HIV testing and treatment in sub‐Saharan Africa

“…These strategies build on the plea for combination efforts for HIV prevention and care, which have progressively been gaining influence among scientists and policy makers 63, 70, 71, 72. While the UTT interventions have been designed to both lessen the burden of HIV infection and reduce vulnerability to HIV acquisition, their effect in real‐world situations remains to be proven.…”

“…The trials deliver a wide range of biomedical, behavioural and structural interventions services to the communities. These strategies build on the plea for combination efforts for HIV prevention and care, which have progressively been gaining influence among scientists and policy makers [63,[70][71][72]. Table 3.…”

Pre-exposure prophylaxis for infants exposed to HIV through breast feeding

“…Scaling up existing interventions and extended access to PrEP to those most in need are the most cost effective ways to stem new HIV infections. 22 Expanding global prevention guidelines to include infant PrEP for infants exposed to HIV by breast feeding could be a major breakthrough as a public health approach to eliminate mother-to-child transmission.…”