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.
Highlights
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
In the deterministic compartmental model, we estimated that PrEP implementation since 2017 could avert 3–63% of total new MSM infections above basecase in Hong Kong in 2017–2021, the extent of which would vary with PrEP coverage and the effectiveness of implementing mixed interventions with the incorporation of test-and-treat intervention
An important finding of our study was that a non-targeting approach could avert more new infections than offering PrEP exclusively to MSM belonging to one distinct risk category
Summary
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. Epidemic control, as reported in Australia[6], rural Zambia[7], UK12, and Canada[13] Some of these modelling studies and a cost-effectiveness analysis study in the Netherlands concluded with the recommendation of prioritizing high-risk groups in low incidence locality for PrEP7,13,14. Among MSM, the HIV prevalence is around 5%, and the annual number of new diagnoses had increased from 170 in 2010 to 464 in 201518, despite the low incidence density of 1.1 per 100 person-year (http://www.chp.gov.hk/files/pdf/interim_statement_on_ hiv_pre_exposure_prophylaxis.pdf). The rates of linkage to and retention in care, treatment initiation and viral load suppression are high (above 70%, http://www.aca.gov.hk/english/strategies/pdf/strategies17-21.pdf) In such setting, it is a challenge to effectively achieve further control of the HIV epidemic in MSM, and PrEP offers a new opportunity
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