Abstract
BackgroundPre-exposure prophylaxis with oral antiretroviral treatment (oral PrEP) for HIV-uninfected injection drug users (IDUs) is potentially useful in controlling HIV epidemics with a significant injection drug use component. We estimated the effectiveness and cost effectiveness of strategies for using oral PrEP in various combinations with methadone maintenance treatment (MMT) and antiretroviral treatment (ART) in Ukraine, a representative case for mixed HIV epidemics.Methods and FindingsWe developed a dynamic compartmental model of the HIV epidemic in a population of non-IDUs, IDUs who inject opiates, and IDUs in MMT, adding an oral PrEP program (tenofovir/emtricitabine, 49% susceptibility reduction) for uninfected IDUs. We analyzed intervention portfolios consisting of oral PrEP (25% or 50% of uninfected IDUs), MMT (25% of IDUs), and ART (80% of all eligible patients). We measured health care costs, quality-adjusted life years (QALYs), HIV prevalence, HIV infections averted, and incremental cost effectiveness. A combination of PrEP for 50% of IDUs and MMT lowered HIV prevalence the most in both IDUs and the general population. ART combined with MMT and PrEP (50% access) averted the most infections (14,267). For a PrEP cost of $950, the most cost-effective strategy was MMT, at $520/QALY gained versus no intervention. The next most cost-effective strategy consisted of MMT and ART, costing $1,000/QALY gained compared to MMT alone. Further adding PrEP (25% access) was also cost effective by World Health Organization standards, at $1,700/QALY gained. PrEP alone became as cost effective as MMT at a cost of $650, and cost saving at $370 or less.ConclusionsOral PrEP for IDUs can be part of an effective and cost-effective strategy to control HIV in regions where injection drug use is a significant driver of the epidemic. Where budgets are limited, focusing on MMT and ART access should be the priority, unless PrEP has low cost.
Highlights
Recent advances in HIV prevention and treatment have increased hope that the global HIV epidemic can be controlled
Oral Pre-exposure prophylaxis with antiretroviral drugs (PrEP) for injection drug users (IDUs) can be part of an effective and cost-effective strategy to control HIV in regions where injection drug use is a significant driver of the epidemic
We developed a dynamic model of HIV transmission and progression which we used to project the evolution of the epidemic under various combinations of strategies for HIV control: oral PrEP programs for uninfected IDUs, maintenance treatment (MMT) programs for IDUs, and scale-up of antiretroviral treatment (ART) programs for eligible HIV-infected individuals
Summary
Recent advances in HIV prevention and treatment have increased hope that the global HIV epidemic can be controlled. New HIV infections have decreased in regions of the world that have traditionally been the source of highest concern, such as countries in sub-Saharan Africa [1]. Despite these encouraging results, in other parts of the world the HIV epidemic continues to grow. In June 2013, a clinical trial of daily oral TDF for uninfected IDUs in Thailand reported a 49% decrease in HIV acquisition due to PrEP [7]. Pre-exposure prophylaxis with oral antiretroviral treatment (oral PrEP) for HIV-uninfected injection drug users (IDUs) is potentially useful in controlling HIV epidemics with a significant injection drug use component. We estimated the effectiveness and cost effectiveness of strategies for using oral PrEP in various combinations with methadone maintenance treatment (MMT) and antiretroviral treatment (ART) in Ukraine, a representative case for mixed HIV epidemics
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