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. 2022 May 1;90(1):41-49.
doi: 10.1097/QAI.0000000000002921.

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

Margo M Wheatley  1 , Gregory Knowlton  1 , Szu-Yu Kao  1 , Samuel M Jenness  2 , Eva A Enns  1
Affiliations

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

Margo M Wheatley et al. J Acquir Immune Defic Syndr. .

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.

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Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1.
Figure 1.. Cost Difference Relative to Status Quo.
Higher spending on PrEP, HIV testing, and interventions results in lower downstream health care costs due to HIV infections averted (negative blue bars). a) When initiation is implemented alone, expenditure on the intervention is far outweighed by the increase in PrEP costs. b) When persistence is implemented, intervention costs ($2,760,000) are offset by savings in healthcare costs (−$5,800,000), but there are still substantial increases in PrEP costs. c) The adherence intervention results in inconsequential differences in HIV testing, PrEP visits, and PrEP drug costs compared to the status quo. Intervention spending is nearly offset by savings in healthcare costs. d) When all three interventions are combined, the largest savings in healthcare costs are achieved, but these savings are only 25% of the increase in spending on PrEP.
Figure 2.
Figure 2.. Cost-effectiveness plane.
Each of the eight strategies are plotted according to their effectiveness (QALYs) and cost. Non-dominated strategies form the efficient frontier (line) and are the subset of strategies that would be considered by a rational decision maker. The cluster of strategies in the top right include initiation, while strategies clustered in the bottom left don’t include initiation. I = initiation, P = persistence, A = adherence.
Figure 3.
Figure 3.. Sensitivity analyses: Optimal strategy using $100,000/QALY gained willingness-to-pay threshold.
a) The cost of PrEP is varied from $250-$2,100/month on the x-axis and the optimal strategy is indicated by color and pattern. When PrEP costs less than $1,003, the triple combination strategy (initiation, adherence, and persistence) is the optimal cost-effective strategy. When PrEP costs increase above $1,644/month, adherence alone becomes the optimal strategy. b) Intervention costs are multiplied on a scale from 0 ($0 intervention costs) to 5 times base case costs. In the first row, all interventions are scaled simultaneously. When costs increase by 1.6 times (60%), no interventions are considered cost-effective and the status quo is the preferred strategy. In the second row, initiation costs are scaled while other intervention costs remain at base case levels. When initiation costs increase by 1.7 times (70%), adherence alone becomes the optimal strategy. In the third and fourth rows, adherence and persistence costs are scaled, respectively, while other intervention costs remain at base case levels. When adherence intervention costs increase by 1.8 times (80%), initiation alone becomes the optimal strategy. Even when the persistence intervention cost $0, the initiation & adherence combination strategy remains optimal. I = initiation, P = persistence, A = adherence.
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  • Reply.
    Nosyk B, Zang X, Krebs E. Nosyk B, et al. J Acquir Immune Defic Syndr. 2022 Oct 1;91(2):e4-e5. doi: 10.1097/QAI.0000000000003034. J Acquir Immune Defic Syndr. 2022. PMID: 36094491 Free PMC article. No abstract available.

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