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Pre-exposure prophylaxis (PrEP) for MSM in low HIV incidence places: should high risk individuals be targeted?
Ngai Sze Wong1, Tsz Ho Kwan2, Owen T Y Tsang3
1Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong, China.
Abstract:
Pre-exposure prophylaxis (PrEP) targeting high-risk men who have sex with men (MSM) has been shown to be a cost-effective HIV control measure. However, the approach could be a challenge in low HIV incidence places with a low proportion of high-risk MSM. To examine the impact of PrEP in such setting in Asia, we developed an epidemic model and conducted cost-effectiveness analysis using empirical multicentre clinical and HIV sequence data from HIV-infected MSM in Hong Kong, in conjunction with behavioural data of local MSM. Without PrEP, the HIV incidence (per 100 person-years) would increase from 1.1 to 1.6 between 2011 and 2021. PrEP could avert 3-63% of total new infections in a five-year period (2017-2021), the variability of which depends on the implementation strategies and combination with test-and-treat. However, under current market drug price in 2016, the incremental cost per quality-adjusted life-year gained (QALYG) of PrEP (USD1583136/QALYG) is almost 3 times higher than test-and-treat intervention alone (USD396874/QALYG). Assuming 93% fall of PrEP drug price and in combination with test-and-treat, putting 30% of MSM on non-targeting PrEP would be more feasible, cost-effective (USD268915/QALYG), and could avert more new infections (40%). PrEP could contribute to HIV epidemic control in a low incidence place.
Insights
Pre-exposure prophylaxis (PrEP) can help control HIV in low-incidence areas. Lowering PrEP drug costs and combining it with other strategies makes it more cost-effective for men who have sex with men (MSM).
Area of Science:
- Public Health
- Epidemiology
- Health Economics
Background:
- Pre-exposure prophylaxis (PrEP) is effective for HIV prevention in high-risk men who have sex with men (MSM).
- Implementing PrEP in low HIV incidence settings with a low proportion of high-risk MSM presents unique challenges.
- Understanding the cost-effectiveness of PrEP in such Asian contexts is crucial for public health policy.
Purpose of the Study:
- To model the impact of PrEP on HIV epidemic control in a low-incidence Asian setting.
- To conduct a cost-effectiveness analysis of PrEP implementation strategies for MSM in Hong Kong.
- To evaluate the influence of drug pricing and combination interventions on PrEP's feasibility.
Main Methods:
- Developed an epidemic model using clinical, HIV sequence, and behavioral data from Hong Kong MSM.
- Performed cost-effectiveness analysis comparing PrEP with test-and-treat strategies.
- Simulated various PrEP implementation scenarios, including different coverage levels and drug prices.
Main Results:
- Without PrEP, HIV incidence among MSM was projected to increase.
- PrEP alone averted 3-63% of new infections, but was highly costly at 2016 drug prices (USD1,583,136/QALYG).
- A 93% drop in PrEP drug price, combined with test-and-treat and 30% non-targeted PrEP coverage, became cost-effective (USD268,915/QALYG) and averted 40% of infections.
Conclusions:
- PrEP can contribute to HIV epidemic control even in low-incidence settings.
- Cost-effectiveness is highly dependent on drug pricing and implementation strategy.
- Combining reduced-cost PrEP with test-and-treat offers a feasible and effective approach for MSM populations.
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