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Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United StatesCost-Effectiveness of PrEP for U.S. PWID

Cora L. Bernard, MS; Margaret L. Brandeau, PhD; Keith Humphreys, PhD; Eran Bendavid, MD, MS; Mark Holodniy, MD; Christopher Weyant, MS; Douglas K. Owens, MD, MS; and Jeremy D. Goldhaber-Fiebert, PhD
[+] Article, Author, and Disclosure Information

This article was published at www.annals.org on 26 April 2016.


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

Disclaimer: The views expressed are those of the authors and do not necessarily reflect the opinion of the Department of Veterans Affairs or U.S. government.

Grant Support: By grant R01-DA15612 from the National Institute on Drug Abuse. Ms. Bernard was supported by a PACCAR Inc. Stanford Graduate Fellowship and a National Science Foundation Graduate Fellowship (DGE-114747). Christopher Weyant was supported by a Stanford Department of Management Science and Engineering Graduate Fellowship and a National Science Foundation Graduate Fellowship (DGE-114747). Drs. Owens, Humphreys, and Holodniy were supported by the Department of Veterans Affairs. Dr. Goldhaber-Fiebert was supported by a Career Development Award (K01AG037593-01A1) from the National Institute on Aging.

Disclosures: Ms. Bernard reports grants from National Science Foundation and Stanford University PACCAR Inc. Graduate Fellowship during the conduct of the study. Dr. Brandeau reports grants from National Institute on Drug Abuse during the conduct of the study. Dr. Weyant reports grants from National Science Foundation during the conduct of the study. Dr. Owens reports grants from NIH during the conduct of the study. Dr. Goldhaber-Fiebert reports grants from NIH/NIA (K01 AG037593) during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictsOfInterestForms.do?msNum=M15-2634.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.

Reproducible Research Statement:Study protocol: Not applicable. Statistical code: Additional detail can be made available where technical appendix is insufficient by contacting Cora Bernard (e-mail, clb210@stanford.edu). Data set: Not applicable.

Requests for Single Reprints: Cora L. Bernard, MS, Department of Management Science and Engineering, Huang Engineering Center, 475 Via Ortega, Stanford University, Stanford, CA 94305-4026; e-mail, clb210@stanford.edu.

Current Author Addresses: Ms. Bernard: Department of Management Science and Engineering, Huang Engineering Center, 475 Via Ortega, Stanford University, Stanford, CA 94305-4026.

Dr. Brandeau: Department of Management Science and Engineering, Huang Engineering Center, 475 Via Ortega, Stanford University, Stanford, CA 94305-4026.

Dr. Humphreys: Stanford School of Medicine, Department of Psychiatry, 401 N. Quarry Road, Room C-305, Stanford, CA 94305-5717.

Dr. Bendavid: Center for Primary Care and Outcomes Research/Center for Health Policy, Stanford University, 117 Encina Commons, Room 204, Stanford, CA 94305-6019.

Dr. Holodniy: AIDS Research Center, VA Palo Alto Health Care System, 3801 Miranda Ave. (132), Palo Alto, California 94304-5107.

Mr. Weyant: Department of Management Science and Engineering, Huang Engineering Center, 475 Via Ortega, Stanford University, Stanford, CA 94305-4026.

Dr. Owens: Center for Primary Care and Outcomes Research/Center for Health Policy , Stanford University, 117 Encina Commons, Stanford, CA 94305-6019.

Dr. Goldhaber-Fiebert: Center for Primary Care and Outcomes Research/Center for Health Policy, Stanford University, 117 Encina Commons, Room 217, Stanford, CA 94305-6019.

Author Contributions: Conception and design: E. Bendavid, C.L. Bernard, M.L. Brandeau, J.D. Goldhaber-Fiebert, K. Humphreys, D.K. Owens, C. Weyant.

Analysis and interpretation of the data: C.L. Bernard, M.L. Brandeau, J.D. Goldhaber-Fiebert, M. Holodniy, K. Humphreys, D.K. Owens, C. Weyant.

Drafting of the article: C.L. Bernard, J.D. Goldhaber-Fiebert, D.K. Owens.

Critical revision for important intellectual content: E. Bendavid, C.L. Bernard, M.L. Brandeau, J.D. Goldhaber-Fiebert, M. Holodniy, K. Humphreys, D.K. Owens.

Final approval of the article: E. Bendavid, C.L. Bernard, M.L. Brandeau, J.D. Goldhaber-Fiebert, M. Holodniy, K. Humphreys, D.K. Owens, C. Weyant.

Statistical expertise: C.L. Bernard, J.D. Goldhaber-Fiebert, D.K. Owens.

Obtaining of funding: M.L. Brandeau, J.D. Goldhaber-Fiebert, D.K. Owens.

Administrative, technical, or logistic support: D.K. Owens.

Collection and assembly of data: E. Bendavid, C.L. Bernard, D.K. Owens, C. Weyant.


Ann Intern Med. 2016;165(1):10-19. doi:10.7326/M15-2634
Text Size: A A A

Background: The total population health benefits and costs of HIV preexposure prophylaxis (PrEP) for people who inject drugs (PWID) in the United States are unclear.

Objective: To evaluate the cost-effectiveness and optimal delivery conditions of PrEP for PWID.

Design: Empirically calibrated dynamic compartmental model.

Data Sources: Published literature and expert opinion.

Target Population: Adult U.S. PWID.

Time Horizon: 20 years and lifetime.

Intervention: PrEP alone, PrEP with frequent screening (PrEP+screen), and PrEP+screen with enhanced provision of antiretroviral therapy (ART) for individuals who become infected (PrEP+screen+ART). All scenarios are considered at 25% coverage.

Outcome Measures: Infections averted, deaths averted, change in HIV prevalence, discounted costs (in 2015 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

Results of Base-Case Analysis: PrEP+screen+ART dominates other strategies, averting 26 700 infections and reducing HIV prevalence among PWID by 14% compared with the status quo. Achieving these benefits costs $253 000 per QALY gained. At current drug prices, total expenditures for PrEP+screen+ART could be as high as $44 billion over 20 years.

Results of Sensitivity Analysis: Cost-effectiveness of the intervention is linear in the annual cost of PrEP and is dependent on PrEP drug adherence, individual transmission risks, and community HIV prevalence.

Limitation: Data on risk stratification and achievable PrEP efficacy levels for U.S. PWID are limited.

Conclusion: PrEP with frequent screening and prompt treatment for those who become infected can reduce HIV burden among PWID and provide health benefits for the entire U.S. population, but, at current drug prices, it remains an expensive intervention both in absolute terms and in cost per QALY gained.

Primary Funding Source: National Institute on Drug Abuse.

Figures

Grahic Jump Location
Figure 1.

Main analysis: incremental costs incurred and QALYs gained.

To assess delivery scenarios, we evaluated 1) PrEP alone with status quo population-level screening rates for people who inject drugs; 2) PrEP with HIV screening every 3 mo (PrEP+screen); and 3) PrEP+screen with prompt and sustained linkage to ART for individuals who do become infected (PrEP+screen+ART). All cases assume 25% coverage, 49% PrEP efficacy, and $10 000 annual PrEP drug cost. The x-axis shows incremental cost in billions of U.S. dollars compared with the status quo of no PrEP; the y-axis shows incremental QALYs in thousands. The point labeled PrEP+screen shows that at current levels of ART initiation and adherence, screening provides a small QALY increase for a large cost increase. When screening is combined with increased ART, however, screening delivers synergistic benefit, resulting in an ICER of $253 000/QALY gained. This scenario, PrEP+screen+ART, dominates the other 2 scenarios (i.e., is more effective and has a lower ICER). ART = antiretroviral therapy; ICER = incremental cost-effectiveness ratio; PrEP = preexposure prophylaxis; QALY = quality-adjusted life-year.

Grahic Jump Location
Grahic Jump Location
Figure 2.

Sensitivity analysis: PrEP value as a function of drug efficacy and drug cost.

We evaluate a program of PrEP with frequent HIV screening and enhanced ART provision (PrEP+screen+ART) with 25% coverage and $10 000 annual PrEP drug cost varying PrEP efficacy from 10% to 90%. The y-axis shows the ICER corresponding to efficacy levels specified on the x-axis. At current drug costs, the cost per QALY gained remains greater than $150 000 for all efficacy levels but substantially decreases as efficacy improves, with the largest jumps in cost-effectiveness coming at lower levels of efficacy. At 49% efficacy (leftmost vertical line), we see our base-case analysis with an ICER of $253 000/QALY gained. The Bangkok Tenofovir Study estimates a 74% reduction (rightmost vertical line) in HIV acquisition for high adherers. This results in a more favorable ICER of $193 000/QALY gained. At a 65% cost reduction PrEP delivers higher value and crosses the $100 000/QALY gained threshold at reported efficacy levels, although low levels of efficacy still result in high ICERs. ART = antiretroviral therapy; ICER = incremental cost-effectiveness ratio; PrEP = preexposure prophylaxis; QALY = quality-adjusted life-year.

Grahic Jump Location

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