Abstract
IntroductionA number of antiretroviral HIV prevention products are efficacious in preventing HIV infection. However, the sexual and reproductive health needs of many women extend beyond HIV prevention, and research is ongoing to develop multi‐purpose prevention technologies (MPTs) that offer dual HIV and pregnancy protection. We do not yet know if these products will be an efficient use of constrained health resources. In this paper, we estimate the cost‐effectiveness of combinations of candidate multi‐purpose prevention technologies (MPTs), in South Africa among general population women and female sex workers (FSWs).MethodsWe combined a cost model with a static model of product impact based on incidence data in South Africa to estimate the cost‐effectiveness of five candidate co‐formulated or co‐provided MPTs: oral PrEP, intravaginal ring, injectable ARV, microbicide gel and SILCS diaphragm used in concert with gel. We accounted for the preferences of end‐users by predicting uptake using a discrete choice experiment (DCE). Product availability and protection were systematically varied in five potential rollout scenarios. The impact model estimated the number of infections averted through decreased incidence due to product use over one year. The comparator for each scenario was current levels of male condom use, while a health system perspective was used to estimate discounted lifetime treatment costs averted per HIV infection. Product benefit was estimated in disability‐adjusted life years (DALYs) averted. Benefits from contraception were incorporated through adjusting the uptake of these products based on the DCE and through estimating the costs averted from avoiding unwanted pregnancies. We explore the additional impact of STI protection through increased uptake in a sensitivity analysis.ResultsAt central incidence rates, all single‐ and multi‐purpose scenarios modelled were cost‐effective among FSWs and women aged 16–24, at a governmental willingness‐to‐pay threshold of $1175/DALY averted (range: $214–$810/DALY averted among non‐dominant scenarios), however, none were cost‐effective among women aged 25–49 (minimum $1706/DALY averted). The cost‐effectiveness of products improved with additional protection from pregnancy. Estimates were sensitive to variation in incidence assumptions, but robust to other parameters.ConclusionsTo the best of our knowledge, this is the first study to estimate the cost‐effectiveness of a range of potential MPTs; suggesting that MPTs will be cost‐effective among higher incidence FSWs or young women, but not among lower incidence older women. More work is needed to make attractive MPTs available to potential users who could use them effectively.
Highlights
| INTRODUCTIONOver the past six years, clinical trials have shown that antiretroviral (ARV)-based pre-exposure prophylaxis (PrEP) can be efficacious in preventing the transmission of human immunodeficiency virus (HIV) [1,2,3,4,5]
A number of antiretroviral human immunodeficiency virus (HIV) prevention products are efficacious in preventing HIV infection
As HIV prevention products come to market, provision alongside contraceptives – when products are of the same modality – could facilitate uptake and adherence, and gauge demand for potential multi-purpose prevention technologies (MPTs) in the future
Summary
Over the past six years, clinical trials have shown that antiretroviral (ARV)-based pre-exposure prophylaxis (PrEP) can be efficacious in preventing the transmission of human immunodeficiency virus (HIV) [1,2,3,4,5]. Protection has been variable during clinical trials and different PrEP modalities have conferred substantially less protection to younger women than older women [4,6]. Both oral and topical PrEP products have been more effective in male populations than females [7,8], partly explained by adherence, and partly by pharmacokinetic data indicating higher drug colorectal drug concentrations than in the female lower genital tract [6,9]. Unlike other PrEP impact models which use expert opinion to inform uptake assumptions, we take a data-driven approach using a discrete choice experiment (DCE) to predict product uptake among different groups [26]. Cost-effectiveness is modelled across three female groups due to differences in epidemiology and HIV risk in each: younger women (aged 16–24), older women (aged 25– 49) and female sex workers (FSWs)
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