The cost-effectiveness of HIV pre-exposure prophylaxis in men who have sex with men and transgender women at high risk of HIV infection in Brazil.

Paula M Luz,Robert A Parker,Elena Losina,Claudio J Struchiner,Kenneth A Freedberg,Beatriz Grinsztejn,Rachel L Maclean,Fabio Mesquita,A David Paltiel,Rochelle P Walensky,Valdilea G Veloso,Madeline E Stern,Benjamin Osher

doi:10.1002/jia2.25096

Abstract

IntroductionMen who have sex with men (MSM) and transgender women (TGW) in Brazil experience high rates of HIV infection. We examined the clinical and economic outcomes of implementing a pre‐exposure prophylaxis (PrEP) programme in these populations.MethodsWe used the Cost‐Effectiveness of Preventing AIDS Complications (CEPAC)‐International model of HIV prevention and treatment to evaluate two strategies: the current standard of care (SOC) in Brazil, including universal ART access (No PrEP strategy); and the current SOC plus daily tenofovir/emtracitabine PrEP (PrEP strategy) until age 50. Mean age (31 years, SD 8.4 years), age‐stratified annual HIV incidence (age ≤ 40 years: 4.3/100 PY; age > 40 years: 1.0/100 PY), PrEP effectiveness (43% HIV incidence reduction) and PrEP drug costs ($23/month) were from Brazil‐based sources. The analysis focused on direct medical costs of HIV care. We measured the comparative value of PrEP in 2015 United States dollars (USD) per year of life saved (YLS). Willingness‐to‐pay threshold was based on Brazil's annual per capita gross domestic product (GDP; 2015: $8540 USD).ResultsLifetime HIV infection risk among high‐risk MSM and TGW was 50.5% with No PrEP and decreased to 40.1% with PrEP. PrEP increased per‐person undiscounted (discounted) life expectancy from 36.8 (20.7) years to 41.0 (22.4) years and lifetime discounted HIV‐related medical costs from $4100 to $8420, which led to an incremental cost‐effectiveness ratio (ICER) of $2530/YLS. PrEP remained cost‐effective (<1x GDP) under plausible variation in key parameters, including PrEP effectiveness and cost, initial cohort age and HIV testing frequency on/off PrEP.ConclusionDaily tenofovir/emtracitabine PrEP among MSM and TGW at high risk of HIV infection in Brazil would increase life expectancy and be highly cost‐effective.

Highlights

Men who have sex with men (MSM) and transgender women (TGW) in Brazil experience high rates of HIV infection
When we assumed that pre-exposure prophylaxis (PrEP)-induced resistance would cause first- and second-line ART to be 10% less effective, the incremental cost-effectiveness ratio (ICER) of PrEP compared to no PrEP (No PrEP) increased by $500/year of life saved (YLS), to $3100/YLS
Compared to standard of care, we found that PrEP was highly cost-effective by gross domestic product (GDP) standards, with an ICER of $2530/YLS (~30% of Brazil’s 2015 per capita GDP, $8540)

Summary

Introduction

Men who have sex with men (MSM) and transgender women (TGW) in Brazil experience high rates of HIV infection. Conclusion: Daily tenofovir/emtracitabine PrEP among MSM and TGW at high risk of HIV infection in Brazil would increase life expectancy and be highly cost-effective. A growing body of evidence supports the use of tenofovir/emtracitabine pre-exposure prophylaxis (PrEP) to prevent HIV infection, in high-risk populations. Recent estimates by the Department of STIs, AIDS and Viral Hepatitis of the Brazilian Ministry of Health report an HIV prevalence of 0.4% in the general population [3]. This figure is much higher among MSM, ranging from 5.2% to 23.7% [4]. HIV risk is even more pronounced among TGW [6]; in Rio de Janeiro, Brazil, their HIV prevalence is estimated at 31.2% [7]

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