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Cost-effectiveness of pre-exposure prophylaxis targeted to high-risk serodiscordant couples as a bridge to sustained ART use in Kampala, Uganda.

Ying R, Sharma M, Heffron R, Celum CL, Baeten JM, Katabira E, Bulya N, Barnabas RV - J Int AIDS Soc (2015)

Bottom Line: Evaluating the cost-effectiveness of implementing time-limited PrEP as a short-term bridge during the first six months of ART for the HIV-positive partner to prevent HIV transmission compared to increasing ART coverage is crucial to informing policy-makers considering PrEP implementation.The incremental cost-effectiveness ratios (ICERs) per HIV infection and disability-adjusted life year (DALY) averted were calculated over 10 years.Using Uganda's gross domestic product per capita of $1681 as a threshold, PrEP and ART for high-risk persons have the potential for synergistic action and are cost-effective in preventing HIV infections in high prevalence settings.

View Article: PubMed Central - PubMed

Affiliation: Department of Global Health, University of Washington, Seattle, WA, USA.

ABSTRACT

Introduction: Despite scale-up of antiretroviral therapy (ART) for treating HIV-positive persons, HIV incidence remains elevated among those at high risk such as persons in serodiscordant partnerships. Antiretrovirals taken by HIV-negative persons as pre-exposure prophylaxis (PrEP) has the potential to avert infections in individuals in serodiscordant partnerships. Evaluating the cost-effectiveness of implementing time-limited PrEP as a short-term bridge during the first six months of ART for the HIV-positive partner to prevent HIV transmission compared to increasing ART coverage is crucial to informing policy-makers considering PrEP implementation.

Methods: To estimate the real world delivery costs of PrEP, we conducted micro-costing and time and motion analyses in an open-label prospective study of PrEP and ART delivery targeted to high-risk serodiscordant couples in Uganda (the Partners Demonstration Project). The cost (in USD, in 2012) of PrEP and ART for serodiscordant couples was assessed, with and without research components, in the study setting. Using Ministry of Health costs, the cost of PrEP and ART provision within a government programme was estimated, as was the cost of providing PrEP in addition to ART. We parameterized an HIV transmission model to estimate the health and economic impacts of 1) PrEP and ART targeted to high-risk serodiscordant couples in the context of current ART use and 2) increasing ART coverage to 55% of HIV-positive persons with CD4 ≤500 cells/µL without PrEP. The incremental cost-effectiveness ratios (ICERs) per HIV infection and disability-adjusted life year (DALY) averted were calculated over 10 years.

Results: The annual cost of PrEP and ART delivery for serodiscordant couples was $1058 per couple in the study setting and $453 in the government setting. The portion of the programme cost due to PrEP was $408 and $92 per couple per year in the study and government settings, respectively. Over 10 years, a programme of PrEP and ART for high-risk serodiscordant couples was projected to avert 43% of HIV infections compared to current practice with an ICER of $1340 per infection averted. This was comparable to ART expansion alone, which would avert 37% of infections with an ICER of $1452.

Conclusions: Using Uganda's gross domestic product per capita of $1681 as a threshold, PrEP and ART for high-risk persons have the potential for synergistic action and are cost-effective in preventing HIV infections in high prevalence settings. The annual cost of PrEP in this programme is less than $100 per serodiscordant couple if implemented in public clinics.

No MeSH data available.


Related in: MedlinePlus

Sensitivity of the ICER per DALY (a) and HIV infection (b) averted for the high-risk serodiscordant couples PrEP programme.The base case ICER is $5354 per DALY averted and $1340 per HIV infection averted.
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Figure 0003: Sensitivity of the ICER per DALY (a) and HIV infection (b) averted for the high-risk serodiscordant couples PrEP programme.The base case ICER is $5354 per DALY averted and $1340 per HIV infection averted.

Mentions: In sensitivity analyses, a high clinic capacity (1500 couples annually, costing $82 per couple) reduced the ICER of the PrEP programme to $4648 per DALY averted, whereas low clinic capacity (200 couples annually, costing $254 per couple) increased the ICER to $18,151 per DALY averted. Similarly, the cost per HIV infection averted increases dramatically with decreased clinic capacity. With ART cost at $100 per person per year, no annual discounting and 10% drop-out from ART and PrEP, the PrEP programme becomes cost-effective for averting DALYs, although the programme never becomes very cost-effective for averting DALYs. For averting HIV infections, PrEP remains the most cost-effective strategy across all ranges of assumptions. It is consistently very cost-effective (i.e. less than Uganda's per capita GDP) except when assuming low per person annual ART cost ($100), in which the ICER per infection averted is $521 for ART scale-up and $1515 for the PrEP programme (Figure 3).


Cost-effectiveness of pre-exposure prophylaxis targeted to high-risk serodiscordant couples as a bridge to sustained ART use in Kampala, Uganda.

Ying R, Sharma M, Heffron R, Celum CL, Baeten JM, Katabira E, Bulya N, Barnabas RV - J Int AIDS Soc (2015)

Sensitivity of the ICER per DALY (a) and HIV infection (b) averted for the high-risk serodiscordant couples PrEP programme.The base case ICER is $5354 per DALY averted and $1340 per HIV infection averted.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4509901&req=5

Figure 0003: Sensitivity of the ICER per DALY (a) and HIV infection (b) averted for the high-risk serodiscordant couples PrEP programme.The base case ICER is $5354 per DALY averted and $1340 per HIV infection averted.
Mentions: In sensitivity analyses, a high clinic capacity (1500 couples annually, costing $82 per couple) reduced the ICER of the PrEP programme to $4648 per DALY averted, whereas low clinic capacity (200 couples annually, costing $254 per couple) increased the ICER to $18,151 per DALY averted. Similarly, the cost per HIV infection averted increases dramatically with decreased clinic capacity. With ART cost at $100 per person per year, no annual discounting and 10% drop-out from ART and PrEP, the PrEP programme becomes cost-effective for averting DALYs, although the programme never becomes very cost-effective for averting DALYs. For averting HIV infections, PrEP remains the most cost-effective strategy across all ranges of assumptions. It is consistently very cost-effective (i.e. less than Uganda's per capita GDP) except when assuming low per person annual ART cost ($100), in which the ICER per infection averted is $521 for ART scale-up and $1515 for the PrEP programme (Figure 3).

Bottom Line: Evaluating the cost-effectiveness of implementing time-limited PrEP as a short-term bridge during the first six months of ART for the HIV-positive partner to prevent HIV transmission compared to increasing ART coverage is crucial to informing policy-makers considering PrEP implementation.The incremental cost-effectiveness ratios (ICERs) per HIV infection and disability-adjusted life year (DALY) averted were calculated over 10 years.Using Uganda's gross domestic product per capita of $1681 as a threshold, PrEP and ART for high-risk persons have the potential for synergistic action and are cost-effective in preventing HIV infections in high prevalence settings.

View Article: PubMed Central - PubMed

Affiliation: Department of Global Health, University of Washington, Seattle, WA, USA.

ABSTRACT

Introduction: Despite scale-up of antiretroviral therapy (ART) for treating HIV-positive persons, HIV incidence remains elevated among those at high risk such as persons in serodiscordant partnerships. Antiretrovirals taken by HIV-negative persons as pre-exposure prophylaxis (PrEP) has the potential to avert infections in individuals in serodiscordant partnerships. Evaluating the cost-effectiveness of implementing time-limited PrEP as a short-term bridge during the first six months of ART for the HIV-positive partner to prevent HIV transmission compared to increasing ART coverage is crucial to informing policy-makers considering PrEP implementation.

Methods: To estimate the real world delivery costs of PrEP, we conducted micro-costing and time and motion analyses in an open-label prospective study of PrEP and ART delivery targeted to high-risk serodiscordant couples in Uganda (the Partners Demonstration Project). The cost (in USD, in 2012) of PrEP and ART for serodiscordant couples was assessed, with and without research components, in the study setting. Using Ministry of Health costs, the cost of PrEP and ART provision within a government programme was estimated, as was the cost of providing PrEP in addition to ART. We parameterized an HIV transmission model to estimate the health and economic impacts of 1) PrEP and ART targeted to high-risk serodiscordant couples in the context of current ART use and 2) increasing ART coverage to 55% of HIV-positive persons with CD4 ≤500 cells/µL without PrEP. The incremental cost-effectiveness ratios (ICERs) per HIV infection and disability-adjusted life year (DALY) averted were calculated over 10 years.

Results: The annual cost of PrEP and ART delivery for serodiscordant couples was $1058 per couple in the study setting and $453 in the government setting. The portion of the programme cost due to PrEP was $408 and $92 per couple per year in the study and government settings, respectively. Over 10 years, a programme of PrEP and ART for high-risk serodiscordant couples was projected to avert 43% of HIV infections compared to current practice with an ICER of $1340 per infection averted. This was comparable to ART expansion alone, which would avert 37% of infections with an ICER of $1452.

Conclusions: Using Uganda's gross domestic product per capita of $1681 as a threshold, PrEP and ART for high-risk persons have the potential for synergistic action and are cost-effective in preventing HIV infections in high prevalence settings. The annual cost of PrEP in this programme is less than $100 per serodiscordant couple if implemented in public clinics.

No MeSH data available.


Related in: MedlinePlus