Abstract

SummaryBackgroundAs antiretroviral therapy (ART) has scaled up and HIV incidence has declined, some have questioned the continued utility of HIV prevention. This study examines the role and cost-effectiveness of HIV prevention in the context of “universal test and treat” (UTT) in three sub-Saharan countries with generalized HIV epidemics.MethodsScenarios were created in Spectrum/Goals models for Lesotho, Mozambique, and Uganda with various combinations of voluntary medical male circumcision (VMMC); pre-exposure prophylaxis; and a highly effective, durable, hypothetical vaccine layered onto three different ART scenarios. One ART scenario held coverage constant at 2008 levels to replicate prevention modeling studies that were conducted prior to UTT. One scenario assumed scale-up to the UNAIDS treatment goals of 90-90-90 by 2025 and 95-95-95 by 2030. An intermediate scenario held ART constant at 2019 coverage. HIV incidence was visualized over time, and cost per HIV infection averted was assessed over 5-, 15-, and 30-year time frames, with 3% annual discounting.FindingsEach prevention intervention reduced HIV incidence beyond what was achieved by ART scale-up alone to the 90-90-90/95-95-95 goals, with near-zero incidence achievable by combinations of interventions covering all segments of the population. Cost-effectiveness of HIV prevention may decrease as HIV incidence decreases, but one-time interventions like VMMC and a durable vaccine may remain cost-effective and even cost-saving as ART is scaled up.InterpretationPrimary HIV prevention is still needed in the era of UTT. Combination prevention is more impactful than a single, highly effective intervention. Broad population coverage of primary prevention, regardless of cost-effectiveness, will be required in generalized epidemic countries to eradicate HIV.

Highlights

  • HIV incidence was visualized over time, and cost per HIV infection averted was assessed over 5, 15, and 30-year time frames, with 3% annual discounting

  • Previous modeling has examined the impact of scaling up biomedical prevention in the context of expanded treatment or has attempted to present an optimized package of interventions, including expanded antiretroviral therapy (ART), but has not explored the role of prevention in the context of universal test and treat (UTT), nor examined the specific characteristics of prevention interventions necessary for impact and cost-effectiveness

  • Primary HIV prevention is still needed in the era of UTT

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Summary

Introduction

Suite 350, Takoma Park, MD 20912, USA. Telephone: (301)www.thelancet.com Vol 46 Month April, 2022As antiretroviral therapy (ART) for HIV treatment has expanded to reach the UNAIDS 90-90-90/9595-95 diagnosis, treatment, and viral suppression targets and evolved into universal test and treat (UTT), new HIV infections have declined, and the numberResearch in contextEvidence before this studyThe authors searched PubMed in October 2020 for studies dating from 2005 to 2020. Search terms included “mathematical modeling” OR “cost-effectiveness” AND “HIV” AND one of the following: “HIV prevention,” “voluntary medical male circumcision,” “pre-exposure prophylaxis,” and “vaccine.”. Previous modeling has examined the impact of scaling up biomedical prevention in the context of expanded treatment or has attempted to present an optimized package of interventions, including expanded ART, but has not explored the role of prevention in the context of universal test and treat (UTT), nor examined the specific characteristics of prevention interventions necessary for impact and cost-effectiveness. Preventing infections with available interventions is more impactful and cost-effective than waiting for the perfect intervention. In settings where intervention targeting to the highest risk populations has minimal impact, one-time interventions such as voluntary medical male circumcision provided to the general population are substantially more cost-effective than those that need to be delivered recurrently

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