0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Original Research |

The Cost-Effectiveness of Preexposure Prophylaxis for HIV Prevention in the United States in Men Who Have Sex With Men

Jessie L. Juusola, MS; Margaret L. Brandeau, PhD; Douglas K. Owens, MD, MS; and Eran Bendavid, MD, MS
[+] Article and Author Information

From Stanford University and Stanford University Medical Center, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California.

Grant Support: By grant R01-DA15612 from the National Institute on Drug Abuse and the Department of Veterans Affairs (Dr. Owens), and grant K01-AI084582 from the National Institute of Allergy and Infectious Diseases (Dr. Bendavid).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2195.

Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Ms. Juusola (e-mail, mailto:jjuusola@stanford.edu).

Requests for Single Reprints: Jessie L. Juusola, MS, Stanford University, Department of Management Science and Engineering, Huang Engineering Center, Suite 263, 475 Via Ortega, Stanford, CA 94305; e-mail, mailto:jjuusola@stanford.edu.

Current Author Addresses: Ms. Juusola: Stanford University, Department of Management Science and Engineering, Huang Engineering Center, Suite 263, 475 Via Ortega, Stanford, CA 94305.

Dr. Brandeau: Stanford University, Department of Management Science and Engineering, Huang Engineering Center, Room 262, 475 Via Ortega, Stanford, CA 94305.

Dr. Owens: Stanford University, Center for Primary Care and Outcomes Research, 117 Encina Commons, Stanford, CA 94305.

Dr. Bendavid: Stanford University, Division of General Internal Medicine, 251 Campus Drive, Medical School Office Building, Room X-332, Stanford, CA 94306.

Author Contributions: Conception and design: J.L. Juusola, M.L. Brandeau, D.K. Owens, E. Bendavid.

Analysis and interpretation of the data: J.L. Juusola, M.L. Brandeau, D.K. Owens, E. Bendavid.

Drafting of the article: J.L. Juusola, E. Bendavid.

Critical revision of the article for important intellectual content: M.L. Brandeau, D.K. Owens, E. Bendavid.

Final approval of the article: J.L. Juusola, M.L. Brandeau, D.K. Owens, E. Bendavid.

Statistical expertise: D.K. Owens, E. Bendavid.

Obtaining of funding: D.K. Owens, E. Bendavid.

Collection and assembly of data: J.L. Juusola, E. Bendavid.


Ann Intern Med. 2012;156(8):541-550. doi:10.7326/0003-4819-156-8-201204170-00004
Text Size: A A A

Background: A recent randomized, controlled trial showed that daily oral preexposure chemoprophylaxis (PrEP) was effective for HIV prevention in men who have sex with men (MSM). The Centers for Disease Control and Prevention recently provided interim guidance for PrEP in MSM at high risk for HIV. Previous studies did not reach a consistent estimate of its cost-effectiveness.

Objective: To estimate the effectiveness and cost-effectiveness of PrEP in MSM in the United States.

Design: Dynamic model of HIV transmission and progression combined with a detailed economic analysis.

Data Sources: Published literature.

Target Population: MSM aged 13 to 64 years in the United States.

Time Horizon: Lifetime.

Perspective: Societal.

Intervention: PrEP was evaluated in both the general MSM population and in high-risk MSM and was assumed to reduce infection risk by 44% on the basis of clinical trial results.

Outcome Measures: New HIV infections, discounted quality-adjusted life-years (QALYs) and costs, and incremental cost-effectiveness ratios.

Results of Base-Case Analysis: Initiating PrEP in 20% of MSM in the United States would reduce new HIV infections by an estimated 13% and result in a gain of 550 166 QALYs over 20 years at a cost of $172 091 per QALY gained. Initiating PrEP in a larger proportion of MSM would prevent more infections but at an increasing cost per QALY gained (up to $216 480 if all MSM receive PrEP). Preexposure chemoprophylaxis in only high-risk MSM can improve cost-effectiveness. For MSM with an average of 5 partners per year, PrEP costs approximately $50 000 per QALY gained. Providing PrEP to all high-risk MSM for 20 years would cost $75 billion more in health care–related costs than the status quo and $600 000 per HIV infection prevented, compared with incremental costs of $95 billion and $2 million per infection prevented for 20% coverage of all MSM.

Results of Sensitivity Analysis: PrEP in the general MSM population would cost less than $100 000 per QALY gained if the daily cost of antiretroviral drugs for PrEP was less than $15 or if PrEP efficacy was greater than 75%.

Limitation: When examining PrEP in high-risk MSM, the investigators did not model a mix of low- and high-risk MSM because of lack of data on mixing patterns.

Conclusion: PrEP in the general MSM population could prevent a substantial number of HIV infections, but it is expensive. Use in high-risk MSM compares favorably with other interventions that are considered cost-effective but could result in annual PrEP expenditures of more than $4 billion.

Primary Funding Source: National Institute on Drug Abuse, Department of Veterans Affairs, and National Institute of Allergy and Infectious Diseases.

Figures

Grahic Jump Location
Appendix Figure 1.

Model schematic.

This schematic presents our deterministic dynamic compartmental model. Each box represents a compartment of the population of men who have sex with men, identified by HIV infection status; screening status; PrEP status; and, if infected, HIV disease stage and treatment status. The number within each square denotes the index number of that compartment. The arrows depict population movement from 1 compartment to another and into or out of the population, with the associated variables representing the rates of change. Appendix Table 1 describes the variables. PrEP = preexposure chemoprophylaxis.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 2.

Prevalence and incidence of HIV with and without PrEP for HIV prevention.

Under each PrEP scenario, persons initiate PrEP immediately and continue PrEP for the 20-y time horizon or until they reach age 65 y, and PrEP is 44% effective. Top. Prevalence in the overall U.S. MSM population, as simulated by our model, for each scenario for the 20-y time horizon. Bottom. Annual HIV incidence in the susceptible U.S. MSM population, as simulated by our model, for each scenario for the 20-y time horizon. The percentage reduction in HIV incidence relative to the status quo is noted for the first and last years of the model time horizon for each scenario. MSM = men who have sex with men; PrEP = preexposure chemoprophylaxis.

Grahic Jump Location
Grahic Jump Location
Figure 1.

Cost-effectiveness of PrEP for HIV prevention.

Incremental costs and QALYs are plotted for each PrEP scenario in the general MSM population and in high-risk MSM, with the origin corresponding to the status quo of no PrEP. The lines show the incremental cost-effectiveness ratio relative to the next lower level of PrEP (the preceding scenario with a lower percentage of MSM starting PrEP). Under each PrEP scenario, persons initiate PrEP immediately and continue PrEP for the 20-y time horizon or until they reach age 65 years, and PrEP is 44% effective and costs $10 083 per year, inclusive of monitoring costs. Incremental costs and QALYs are calculated over a 20-y time horizon and are discounted to the present at 3% annually. H-R = high-risk; MSM = men who have sex with men; PrEP = preexposure chemoprophylaxis; QALY = quality-adjusted life-year.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 3.

Costs of PrEP for HIV prevention as a function of the percentage of uninfected MSM receiving PrEP.

Total costs of PrEP over 20 y are plotted for each use scenario in the general MSM population (top) and in high-risk MSM (bottom). Total costs of PrEP include the cost of antiretroviral drugs for PrEP, costs of monitoring tests and physician visits, and initiation and discontinuation costs. Under each PrEP scenario, persons initiate PrEP immediately and continue PrEP for the 20-y time horizon or until they reach age 65 y, and PrEP is assumed to be 44% effective and cost $10 083 per year. Costs are calculated over a 20-y time horizon and are discounted to the present at 3% annually. MSM = men who have sex with men; PrEP = preexposure chemoprophylaxis.

Grahic Jump Location
Grahic Jump Location
Figure 2.

Cost-effectiveness of PrEP for HIV prevention as a function of PrEP efficacy and cost.

This 2-way sensitivity analysis shows ranges of the ICER for initiating PrEP in 20% of the general MSM population (top) and in all high-risk MSM (bottom) as a function of PrEP efficacy and cost. Costs depicted on the vertical axes are annual and include all antiretroviral drug and monitoring costs. Incremental costs and QALYs used to calculate the ICERs are calculated over a 20-y time horizon and are discounted to the present at 3% annually. ICER = incremental cost-effectiveness ratio; MSM = men who have sex with men; PrEP = preexposure chemoprophylaxis; QALY = quality-adjusted life-year.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 4.

ICER of PrEP for HIV prevention in all high-risk MSM as a function of HIV prevalence.

In the PrEP scenario, all high-risk MSM initiate PrEP immediately and continue PrEP for the 20-y time horizon or until they reach age 65 years. Incremental costs and QALYs used to calculate the ICER are calculated over a 20-y time horizon and are discounted to the present at 3% annually. ICER = incremental cost-effectiveness ratio; MSM = men who have sex with men; PrEP = preexposure chemoprophylaxis; QALY = quality-adjusted life-year.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 5.

Tornado diagram of the factors that affect the cost-effectiveness of PrEP for HIV prevention in all high-risk MSM.

The bars show the range of the ICER as each variable is varied by the range listed. The ICER in the base case, $52 443, is shown by the vertical line. In each scenario, all high-risk MSM initiate PrEP immediately and continue PrEP for the 20-y time horizon or until they reach age 65 y. Incremental costs and QALYs used to calculate the ICER are calculated over a 20-y time horizon and are discounted to the present at 3% annually. ICER = incremental cost-effectiveness ratio; MSM = men who have sex with men; PrEP = preexposure chemoprophylaxis; QALY = quality-adjusted life-year.

Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Submit a Comment

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)