Potential Clinical and Economic Value of Long-Acting Preexposure Prophylaxis for South African Women at High-Risk for HIV Infection

BACKGROUND:

For young South African women at risk for human immunodeficiency virus (HIV) infection, preexposure prophylaxis (PrEP) is one of the few effective prevention options available. Long-acting injectable PrEP, which is in development, may be associated with greater adherence, compared with that for existing standard oral PrEP formulations, but its likely clinical benefits and additional costs are unknown.

METHODS:

Using a computer simulation, we compared the following 3 PrEP strategies: no PrEP, standard PrEP (effectiveness, 62%; cost per patient, $150/year), and long-acting PrEP (effectiveness, 75%; cost per patient, $220/year) in South African women at high risk for HIV infection (incidence of HIV infection, 5%/year). We examined the sensitivity of the strategies to changes in key input parameters among several outcome measures, including deaths averted and program cost over a 5-year period; lifetime HIV infection risk, survival rate, and program cost and cost-effectiveness; and budget impact.

RESULTS:

Compared with no PrEP, standard PrEP and long-acting PrEP cost $580 and $870 more per woman, respectively, and averted 15 and 16 deaths per 1000 women at high risk for infection, respectively, over 5 years. Measured on a lifetime basis, both standard PrEP and long-acting PrEP were cost saving, compared with no PrEP. Compared with standard PrEP, long-acting PrEP was very cost-effective ($150/life-year saved) except under the most pessimistic assumptions. Over 5 years, long-acting PrEP cost $1.6 billion when provided to 50% of eligible women.

CONCLUSIONS:

Currently available standard PrEP is a cost-saving intervention whose delivery should be expanded and optimized. Long-acting PrEP will likely be a very cost-effective improvement over standard PrEP but may require novel financing mechanisms that bring short-term fiscal planning efforts into closer alignment with longer-term societal objectives.

Below:  Average discounted per-person lifetime cost distribution of the no preexposure prophylaxis (PrEP), standard PrEP (Std-PrEP), and long-acting PrEP (LA-PrEP) strategies

Below:  Cumulative discounted costs, human immunodeficiency virus (HIV)–related deaths, and women receiving antiretroviral therapy (ART) for the no preexposure prophylaxis (PrEP), standard PrEP (Std-PrEP), and long-acting PrEP (LA-PrEP) strategies.

By:   Walensky RP1, Jacobsen MM2, Bekker LG3, Parker RA4, Wood R3, Resch SC5, Horstman NK2, Freedberg KA6, Paltiel AD7.

• 1Medical Practice Evaluation Center Division of Infectious Disease Division of General Internal Medicine Division of Infectious Disease, Brigham and Women's Hospital Harvard University Center for AIDS Research, Harvard Medical School.
• 2Medical Practice Evaluation Center Division of General Internal Medicine.
• 3Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Medicine, University of Cape Town, South Africa.
• 4Medical Practice Evaluation Center Division of General Internal Medicine MGH Biostatistics Center, Massachusetts General Hospital Harvard University Center for AIDS Research, Harvard Medical School.
• 5Center for Health Decision Science.
• 6Medical Practice Evaluation Center Division of Infectious Disease Division of General Internal Medicine Harvard University Center for AIDS Research, Harvard Medical School Department of Health Policy and Management, Harvard T. H. Chan School of Public Health Department of Epidemiology, Boston University School of Public Health, Massachusetts.
• 7Yale School of Public Health, New Haven, Connecticut. 

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