Abstract
Daily pre-exposure prophylaxis (PrEP) and treatment-as-prevention (TasP) reduce HIV acquisition and transmission risk, respectively. A demonstration study (2015-2017) assessed TasP and PrEP feasibility among female sex workers (FSW) in Cotonou, Benin. Cotonou, Benin. We developed a compartmental HIV transmission model featuring PrEP and antiretroviral therapy (ART) among the high-risk (FSW and clients) and low-risk populations, calibrated to historical epidemiological and demonstration study data, reflecting observed lower PrEP uptake, adherence and retention compared with TasP. We estimated the population-level impact of the 2-year study and several 20-year intervention scenarios, varying coverage and adherence independently and together. We report the percentage [median, 2.5th-97.5th percentile uncertainty interval (95% UI)] of HIV infections prevented comparing the intervention and counterfactual (2017 coverages: 0% PrEP and 49% ART) scenarios. The 2-year study (2017 coverages: 9% PrEP and 83% ART) prevented an estimated 8% (95% UI 6-12) and 6% (3-10) infections among FSW over 2 and 20 years, respectively, compared with 7% (3-11) and 5% (2-9) overall. The PrEP and TasP arms prevented 0.4% (0.2-0.8) and 4.6% (2.2-8.7) infections overall over 20 years, respectively. Twenty-year PrEP and TasP scale-ups (2035 coverages: 47% PrEP and 88% ART) prevented 21% (17-26) and 17% (10-27) infections among FSW, respectively, and 5% (3-10) and 17% (10-27) overall. Compared with TasP scale-up alone, PrEP and TasP combined scale-up prevented 1.9× and 1.2× more infections among FSW and overall, respectively. The demonstration study impact was modest, and mostly from TasP. Increasing PrEP adherence and coverage improves impact substantially among FSW, but little overall. We recommend TasP in prevention packages.
Highlights
We developed a compartmental HIV transmission model featuring pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) among the high-risk (FSW and clients) and low-risk populations, calibrated to historical epidemiological and demonstration study data, reflecting observed lower PrEP uptake, adherence and retention compared with TasP
The 2015 HIV prevalence in Cotonou among professional and part-time female sex workers (FSW) remains high at 17% and 8%, respectively,[17] compared with 2% in the general population in 2012.21 Currently, the national ART coverage levels are far below UNAIDS 2020 90-90-90 targets [90% of people living with HIV (PLHIV) diagnosed, 90% of diagnosed on ART, and 90% on ART virally suppressed], with 66% of women and 45% of men living with HIV estimated to be on ART in 2017.22 In 2015, only 24% of FSW living with HIV in Cotonou were on ART.[23]
Model results suggest that between 2015 and 2017 the 2-year PrEP/TasP study prevented a median of 8% (95% uncertainty interval (UI) 6–12), 17% (95% UI 10–29), and 7% (95% UI 3–11) of new HIV infections among all professional FSW (pFSW), clients, and in the whole population, respectively, representing 4 (2–5), 49 (27–91), and 72 (41–119) infections prevented (Fig. 2A)
Summary
Pre-exposure prophylaxis (PrEP) and treatment-asprevention (TasP) [rapid test-and-treat antiretroviral therapy (ART)] are 2 key HIV prevention interventions,[1,2,3,4] with very high individual-level efficacy if there is adequate adherence.[5,6,7,8] Clinical trials of PrEP among high-risk women in sub-Saharan Africa have shown mixed effectiveness results, partly due to poor adherence.[9,10,11] After concerns of oral PrEP uptake and feasibility in real-life settings, several demonstration studies have been conducted among female sex workers (FSW),[12] but to date, no modeling impact analyses assessing the impact of PrEP have reflected these real-life data.[13] Despite this, PrEP is being offered and adopted across the region.[14] As in many West African countries, the HIV epidemic in Benin has remained concentrated in key populations, with FSW disproportionately affected by HIV,[15,16] exacerbated by the illegal status of sex work in Benin and other economic, structural, and social barriers to accessing health services. Pre-exposure prophylaxis (PrEP) and treatment-as-prevention (TasP) reduce HIV acquisition and transmission risk, respectively. A demonstration study (2015–2017) assessed TasP and PrEP feasibility among female sex workers (FSW) in Cotonou, Benin
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