Cost-Effectiveness of Interventions to Improve HIV Pre-Exposure Prophylaxis Initiation, Adherence, and Persistence among Men Who Have Sex with Men

SUMMARY 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 for men who have sex with men (MSM) in Atlanta, Georgia, 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 eight intervention strategies using a health sector perspective. Strategies included a status quo (no interventions), three 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. Findings Strategies averted 0.2–4.2% new infections and gained 0.0045%–0.24% QALYs compared to 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 with an incremental cost-effectiveness ratio of $86,927/QALY gained. Sensitivity analyses showed no strategies were cost-effective when intervention costs increased by 60% and the strategy combining all three interventions was cost-effective when PrEP costs decreased to $1,000/month. Interpretation Under reasonable assumptions of intervention uptake and cost, PrEP initiation interventions achieved moderate public health gains and could be cost-effective. However, these analyses demonstrate that substantial financial resources will be needed to improve the PrEP care continuum towards meeting EHE goals. Funding US National Institutes of Health RESEARCH IN CONTEXT Evidence before this study We searched PubMed for articles published between 2010-2020 using the term “((“Costs and Cost Analysis”[Mesh]) OR “Cost-Benefit Analysis”[Mesh] OR cost-effective* OR cost-utility OR “economic evaluation” OR “economic impact”) AND (“HIV”[Mesh] OR HIV OR HIV/AIDS) AND (pre-exposure OR PrEP) AND (MSM OR gay OR bisexual OR GBM),” which yielded 79 results. PrEP (compared to no PrEP) for high-risk MSM is generally found to be cost-effective in the United States and other high-income countries, with some variation in findings. However, evidence on the cost and cost-effectiveness of interventions designed to address barriers to effective PrEP use are lacking. Current studies typically model hypothetical improvements that may not be realistically achieved. Added value of this study Using a stochastic network-based model of HIV, we projected the potential costs, benefits, and cost-effectiveness of real-world interventions to improve PrEP use through increased initiation, adherence, and persistence among MSM in a US urban center. We found real-world interventions to improve PrEP use could be cost-effective, however they would be expensive and achieve only limited clinical gains. Implications of all the available evidence Lower PrEP costs would improve the cost-effectiveness of expanding and improving PrEP use. Continued expansion of PrEP coverage beyond current levels will likely involve multiple interventions of increasing intensity and cost to engage harder-to-reach populations. Realistic efforts to end the HIV epidemic may require investments and interventions that are above currently accepted willingness-to-pay thresholds.