Modelling impact and cost‐effectiveness of oral pre‐exposure prophylaxis in 13 low‐resource countries

Abstract

Introduction Oral pre‐exposure prophylaxis (PrEP) provision is a priority intervention for high HIV prevalence settings and populations at substantial risk of HIV acquisition. This mathematical modelling analysis estimated the impact, cost and cost‐effectiveness of scaling up oral PrEP in 13 countries. Methods We projected the impact and cost‐effectiveness of oral PrEP between 2018 and 2030 using a combination of the Incidence Patterns Model and the Goals model. We created four PrEP rollout scenarios involving three priority populations—female sex workers (FSWs), serodiscordant couples (SDCs) and adolescent girls and young women (AGYW)—both with and without geographic prioritization. We applied the model to 13 countries (Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Mozambique, Namibia, Nigeria, Tanzania, Uganda, Zambia and Zimbabwe). The base case assumed achievement of the Joint United Nations Programme on HIV/AIDS 90‐90‐90 antiretroviral therapy targets, 90% male circumcision coverage by 2020 and 90% efficacy and adherence levels for oral PrEP. Results In the scenarios we examined, oral PrEP averted 3% to 8% of HIV infections across the 13 countries between 2018 and 2030. For all but three countries, more than 50% of the HIV infections averted by oral PrEP in the scenarios we examined could be obtained by rollout to FSWs and SDCs alone. For several countries, expanding oral PrEP to include medium‐risk AGYW in all regions greatly increased the impact. The efficiency and impact benefits of geographic prioritization of rollout to AGYW varied across countries. Variations in cost‐effectiveness across countries reflected differences in HIV incidence and expected variations in unit cost. For most countries, rolling out oral PrEP to FSWs, SDCs and geographically prioritized AGYW was not projected to have a substantial impact on the supply chain for antiretroviral drugs. Conclusions These modelling results can inform prioritization, target‐setting and other decisions related to oral PrEP scale‐up within combination prevention programmes. We caution against extensive use given limitations in cost data and implementation approaches. This analysis highlights some of the immediate challenges facing countries—for example, trade‐offs between overall impact and cost‐effectiveness—and emphasizes the need to improve data availability and risk assessment tools to help countries make informed decisions.

Adoption of guidelines on and use of oral pre-exposure prophylaxis: a global summary and forecasting study

“… 27 , 28 The inclusion of PrEP services for adolescent girls and young women, primarily in the African region, has resulted in a large increase in young women having received PrEP. This increasing use of PrEP has potential to decrease HIV incidence, particularly in more generalised epidemics, 29 although PrEP continuation has been a challenge. 23 …”

“…27,28 The inclusion of PrEP services for adolescent girls and young women, primarily in the African region, has resulted in a large increase in young women having received PrEP. This increasing use of PrEP has potential to decrease HIV incidence, particularly in more generalised epidemics, 29 although PrEP continuation has been a challenge. 23 Although we made every effort to obtain the most upto-date PrEP user data and to ensure that these data had been verified, information was missing for some countries.…”

Understanding PrEP Acceptability Among Priority Populations: Results from a Qualitative Study of Potential Users in Central Uganda

“…PrEP implementation programs have demonstrated the feasibility of delivering PrEP in a variety of settings [5][6][7][8]. If implemented successfully, use of oral PrEP among Ugandan female sex workers (FSW), serodiscordant couples (SDC), and adolescent girls and young women (AGYW), alone, could prevent nearly 9% of anticipated HIV infections from 2018 to 2030 [9]. While the number of countries implementing PrEP has increased in recent years, sub-Saharan Africa accounts for only 44% of global PrEP initiations despite accounting for more than 70% of the global burden of HIV infection [10,11].…”

Individual and community-level benefits of PrEP in western Kenya and South Africa: Implications for population prioritization of PrEP provision

“…As the impact of PrEP on the HIV epidemic depends on the network characteristics of not just the PrEP recipients, but also their partners, and their partners' partners, the use of a network-based model allows for realistic estimation of community-level health benefits. Previous mathematical modelling [33] demonstrated that earmarking prevention interventions to key population groups like female sex workers can significantly reduce HIV incidence, but large-scale impact in mature epidemics will require interventions for both key and non-key populations [34]. Indeed, our analyses showed the impact for a given set of resources may still be high when directed to a less connected, but more at-risk, population group, highlighting the importance of providing PrEP to general population groups at elevated risk.…”