Cost-Effectiveness of Interventions to Improve HIV Pre-exposure Prophylaxis Initiation, Adherence, and Persistence Among Men Who Have Sex With Men

• Type of Material: Article
• Authors: Margo M Wheatley, University of Minnesota, Minneapolis; Gregory Knowlton, University of Minnesota, Minneapolis; Szu-Yu Kao, University of Minnesota, Minneapolis; Samuel Jenness, Emory University; Eva A Enns, University of Minnesota, Minneapolis
• Language: English
• Date: 2022-05-01
• Publisher: LIPPINCOTT WILLIAMS & WILKINS
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2022 Wolters Kluwer Health, Inc. All rights reserved.
• Final Published Version (URL): http://dx.doi.org/10.1097/QAI.0000000000002921
• Title of Journal or Parent Work: JAIDS-JOURNAL OF ACQUIRED IMMUNE DEFICIENCY SYNDROMES
• Volume: 90
• Issue: 1
• Start Page: 41
• End Page: 49
• Grant/Funding Information: This work was supported by National Institutes of Health grant R01 AI138783.
• Keywords: Life Sciences & Biomedicine; Science & Technology; cost-effectiveness; Immunology; HIV; AIDS; pre-exposure prophylaxis; Infectious Diseases; RETENTION; IMPACT; CONTINUUM; CARE

Abstract

Background:To help achieve Ending the HIV Epidemic (EHE) goals of reducing new HIV incidence, pre-exposure prophylaxis (PrEP) use and engagement must increase despite multidimensional barriers to scale-up and limitations in funding. We investigated the cost-effectiveness of interventions spanning the PrEP continuum of care.Setting:Men who have sex with men in Atlanta, GA, a focal jurisdiction for the EHE plan.Methods:Using a network-based HIV transmission model, we simulated lifetime costs, quality-adjusted life years (QALYs), and infections averted for 8 intervention strategies using a health sector perspective. Strategies included a status quo (no interventions), 3 distinct interventions (targeting PrEP initiation, adherence, or persistence), and all possible intervention combinations. Cost-effectiveness was evaluated incrementally using a $100,000/QALY gained threshold. We performed sensitivity analyses on PrEP costs, intervention costs, and intervention coverage.Results:Strategies averted 0.2%-4.2% new infections and gained 0.0045%-0.24% QALYs compared with the status quo. Initiation strategies achieved 20%-23% PrEP coverage (up from 15% with no interventions) and moderate clinical benefits at a high cost, while adherence strategies were relatively low cost and low benefit. Under our assumptions, the adherence and initiation combination strategy was cost-effective ($86,927/QALY gained). Sensitivity analyses showed no strategies were cost-effective when intervention costs increased by 60% and the strategy combining all 3 interventions was cost-effective when PrEP costs decreased to $1000/month.Conclusion:PrEP initiation interventions achieved moderate public health gains and could be cost-effective. However, substantial financial resources would be needed to improve the PrEP care continuum toward meeting EHE goals.