Abstract
Antiretrovirals have substantial promise for HIV-1 prevention, either as antiretroviral treatment (ART) for HIV-1-infected persons to reduce infectiousness, or as pre-exposure prophylaxis (PrEP) for HIV-1-uninfected persons to reduce the possibility of infection with HIV-1. HIV-1 serodiscordant couples in long-term partnerships (one member is infected and the other is uninfected) are a priority for prevention interventions. Earlier ART and PrEP might both reduce HIV-1 transmission in this group, but the merits and synergies of these different approaches have not been analyzed. We constructed a mathematical model to examine the impact and cost-effectiveness of different strategies, including earlier initiation of ART and/or PrEP, for HIV-1 prevention for serodiscordant couples. Although the cost of PrEP is high, the cost per infection averted is significantly offset by future savings in lifelong treatment, especially among couples with multiple partners, low condom use, and a high risk of transmission. In some situations, highly effective PrEP could be cost-saving overall. To keep couples alive and without a new infection, providing PrEP to the uninfected partner could be at least as cost-effective as initiating ART earlier in the infected partner, if the annual cost of PrEP is <40% of the annual cost of ART and PrEP is >70% effective. Strategic use of PrEP and ART could substantially and cost-effectively reduce HIV-1 transmission in HIV-1 serodiscordant couples. New and forthcoming data on the efficacy of PrEP, the cost of delivery of ART and PrEP, and couples behaviours and preferences will be critical for optimizing the use of antiretrovirals for HIV-1 prevention. Please see later in the article for the Editors' Summary.
Highlights
Thirty years after HIV-1 was first recognized, the epidemic continues with 2.6 million people newly infected in the past year [1]
Antiretroviral therapy (ART) can dramatically improve the survival of HIV-1–infected persons and is the cornerstone of strategies to prevent vertical HIV-1 transmission [2,3]. 5.2 million people living with HIV-1 in low- and middle-income countries have been provided with life-saving antiretroviral treatment (ART) [1]; reduced funding for AIDS programs as a result of the global economic crisis threatens these acheivements, and a sustainable response to the HIV-1 epidemic requires a large reduction in the numbers becoming infected [1,4,5]
Four clinical trials have closed confirming that antiretrovirals have the potential to be used as: (i) ART to reduce the infectiousness of HIV-1–infected persons [9], and (ii) oral or topical pre-exposure prophylaxis (PrEP) for uninfected persons to reduce acquisition [10,11,12]
Summary
Thirty years after HIV-1 was first recognized, the epidemic continues with 2.6 million people newly infected in the past year [1]. Four clinical trials have closed confirming that antiretrovirals have the potential to be used as: (i) ART to reduce the infectiousness of HIV-1–infected persons [9], and (ii) oral or topical pre-exposure prophylaxis (PrEP) for uninfected persons to reduce acquisition [10,11,12]. Antiretrovirals have substantial promise for HIV-1 prevention, either as antiretroviral treatment (ART) for HIV-1–infected persons to reduce infectiousness, or as pre-exposure prophylaxis (PrEP) for HIV-1–uninfected persons to reduce the possibility of infection with HIV-1. ART could be given to HIVuninfected people to reduce acquisition of the virus This approach—preexposure prophylaxis (PrEP)—has provided protection against HIV transmission in some but not all clinical trials
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