Preexposure prophylaxis for men who have sex with men in the Netherlands: impact on HIV and Neisseria gonorrhoeae transmission and cost-effectiveness

Abstract

Objectives: To assess the impact of a preexposure prophylaxis (PrEP) programme for high-risk men who have sex with men (MSM), which includes gonorrhoea testing and treatment, on the transmission of HIV and Neisseria among MSM in the Netherlands and the cost-effectiveness of such programme with and without risk compensation (in the form of reduced condom use). Methods: We developed a stochastic agent-based transmission model of HIV and gonorrhoea. We simulated a capped (max 2.5% of MSM) and uncapped (5.5% of MSM in 2018 declining to 3% in 2027) daily PrEP programme for high-risk MSM, with 3-monthly HIV and gonorrhoea testing, with and without risk compensation. Epidemiological outcomes were calculated from the transmission model and used in an economic model to calculate costs, quality-adjusted life-years (QALY), and incremental cost-effectiveness ratios (ICER), over 2018–2027, taking a healthcare payer perspective. Results: Without risk compensation, PrEP can lead to a reduction of 61 or 49% in the total number of new HIV infections in 2018–2027, if the programme is uncapped or capped to 2.5% of MSM, respectively. With risk compensation, this reduction can be 63 or 46% in the uncapped and capped programmes, respectively. In all scenarios, gonorrhoea prevalence decreased after introducing PrEP. Without risk compensation, 92% of simulations were cost-effective (of which 52% cost-saving). With risk compensation, 73% of simulations were cost-effective (of which 23% was cost-saving). Conclusion: A nationwide PrEP programme for high-risk MSM can result in substantial reductions in HIV and gonorrhoea transmission and be cost-effective, even with risk compensation.

Cost-Effectiveness Analysis of the Daily HIV Pre-Exposure Prophylaxis in Men who Have Sex with Men in Barcelona

“…The number of people undergoing PrEP in the Catalan population is 2,400, constituting approximately half of all patients treated in Spain. Applying the same deterministic compartmental mathematical model used by Nichols et al and Van de Vijver et al, and in line with other studies, favourable cost-effectiveness results have been obtained, that estimate a saving of 93.8 million over a 40-year horizon for a daily regimen and considering, for a conservative scenario, an effectiveness of 86% taken as a reference from other studies [5][6][7][8][9].…”

“…Thus, the cost savings are due in part to the start of PrEP in Spain, in November 2019, using the generic presentation of the drugs, which made the global annual cost of PrEP in Spain for a person during the first year of treatment to significantly decrease to €1,433.84. With no adjustment, the difference in PrEP costs between the available literature in other countries and this study varies between €-600.93 (generic presentation and daily administration regimen) [6] and €5,966.16 (daily regimen, commercial presentation) [5,9]. Even when the heterogeneity in PrEP administration is accounted for, the difference in prices is still relevant for the available literature.…”

“…Finally, a reduction in price of 50% following the approval of an on-demand PrEP regime , as assumed in other studies [Nichols et al, 2016;Reitsema et al, 2020], does not affect health outcomes, but generates healthcare savings of 152.4 million euros, which start to accrue as soon as 8 years and 8 months after deployment. The results obtained can be extrapolated to an increased-effectiveness scenario (98%), thus resulting in a total cumulative saving of 218 million euros.…”

“…Conducting a prospective study, evidence from France and Canada shows that the yearly costs accrued from avoiding one infection are 75,258€ with no price reduction, 39,970€ with generic TDF/FTC [8]. Also performed in the Netherlands, the most recently reviewed study shows that 92% and 73% of the simulations were cost-effective, of which 52% and 23% were cost-saving (respectively, without and with risk compensation) [9]. Although all this evidence suggests scenarios in which the intervention can be cost-effective, the case has never been studied in Catalonia, a territory with extensive implementation of PrEP.…”

Slow Uptake of PrEP: Behavioral Predictors and the Influence of Price on PrEP Uptake Among MSM with a High Interest in PrEP

“…Despite its effectiveness and these efforts, the accessibility of PrEP varies greatly per country [ 8 ], the uptake of PrEP has been low [ 9 ], and the full potential of PrEP at population level has not been reached yet [ 10 ]. In the Netherlands, it is estimated that there are currently 3500 individuals on PrEP [ 8 ], of which 95% are MSM [ 11 ], while it is estimated that 10,000 MSM meet eligibility criteria for PrEP [ 12 , 13 ]. To increase uptake, it is therefore important to identify facilitators and barriers of PrEP use.…”