Cost Of Pre-exposure Prophylaxis Research Articles

The Budget Impact of Adopting Oral Pre-Exposure Prophylaxis for HIV Prevention: A Rapid Review

The World Health Organization (WHO) recommended the use of oral pre-exposure prophylaxis (PrEP) for HIV prevention in 2015. Although the number of countries with national PrEP recommendations increased from 2 in 2015 to 121 in 2019, there has been slow progress in Africa. The reason for this slow progress is that developing countries have budgetary constraints. Budget impact analysis (BIA) is an economic analysis that can help explore the affordability of oral PrEP. A rapid review was conducted to summarise the existing literature on the budget impact of adopting oral PrEP for HIV prevention. PubMed and Google Scholar databases were searched for relevant studies. Studies included in the review utilised primary data. Eleven studies met the inclusion criteria. This review reveals that most studies took a healthcare service provider perspective, targeted men who have sex with men (MSM), had time horizons of more than 10 years, used macro-costing, and performed univariate sensitivity analysis and discounting. If countries wish to perform a budget impact analysis of adopting oral PrEP for HIV prevention, we recommend that they select a target population that is most at risk of acquiring HIV. In addition, a time horizon of ten years or more should be used, and accurate values of the cost of oral PrEP and antiretroviral therapy (ART) and adherence to oral PrEP should be researched. Furthermore, deterministic sensitivity analysis should be carried out instead of probabilistic sensitivity analysis (PSA), as the degree of variability and the extent of the correlation among the parameters may not be known.

Leveraging international stakeholders’ experiences with oral PrEP costs to accelerate implementation of the monthly dapivirine vaginal ring: A qualitative study

BackgroundCosting and financing systematic implementation are recognized barriers to human immunodeficiency virus (HIV) prevention. In the absence of empiric implementation and economic data, perspectives from international stakeholders involved in developing and supporting daily oral pre-exposure prophylaxis (PrEP) policy, and programs can provide critical insights for developing costed plans to support and accelerate the rollout of novel long-acting PrEP (LA-PrEP) methods, such as the monthly dapivirine vaginal ring (PrEP ring).MethodsWe interviewed stakeholders from purposively selected international organizations about anticipated PrEP-ring implementation costs, evidence gaps and key process steps for developing a costed rollout plan template (CRPT). We deductively analysed interviews.ResultsThe 27 stakeholders (11 donors, 10 nongovernmental, 4 academic/research, 2 multilateral) identified 10 cost-related themes: 7 for planning and implementation and 3 for financing, costing and budgeting. Planning and implementation cost considerations included: (1) actionable target setting; (2) multilevel communication strategies for awareness-raising, demand creation, client-level adherence and choice counselling; (3) human resources, encompassing task shifting and integration into non-HIV services; (4) supply chain costs, including commodities, manufacturing diversification, packaging and forecasting; (5) laboratory infrastructure and monitoring; (6) updated health information systems and metrics to monitor and evaluate multiple methods integrated into HIV, non-HIV and de-medicalized delivery settings; and (7) technical assistance and knowledge management. Themes for financing, costing and budgeting comprised: (8) cost and budget analyses, such as cost–effectiveness; (9) economic evidence gaps on service integration; and (10) innovative or co-financing for sustainable and equitable allocation of limited financial resources to support accelerated PrEP-ring delivery. We organized these themes within the CRPT.ConclusionsThe CRPT could expedite planning and enhance the pace and scale of optimized, systematic and sustainable delivery of PrEP methods. Further research is needed to evaluate use cases of the CRPT.

Perceived Versus Actual Costs of HIV Pre-Exposure Prophylaxis Among Gay, Bisexual, and Other Men Who Have Sex with Men in the United States.

Gay, bisexual, and other men who have sex with men (GBMSM) account for the highest proportion of HIV diagnoses in the United States, with daily pre-exposure prophylaxis (PrEP) significantly reducing transmission risk. Since 2021, the Affordable Care Act rules have required PrEP and accompanying care visits to be free for most Americans; nevertheless, insurers have found ways to circumvent no-cost PrEP and some employers are receiving exemptions from including it in their formularies. Despite this, perceived costs and indirect expenses still hinder PrEP adoption. This study examines the differences between perceived and actual costs among GBMSM who have and have not used PrEP. We conducted a one-time online survey with 692 adults from six New England states between May 2020 and October 2021. Participants who had never used PrEP estimated its cost, while those with prior PrEP experience reported their actual expenses. Bivariate analysis and multi-variable logistic regression were used to assess the data. Results showed a 60% difference between perceived ($48) and actual ($30) median monthly costs. Higher perceived costs among nonusers were linked to race and income, while high actual costs for prior users were associated with insurance type, income, wealth, race, and self-rated consumer credit. This significant disparity in PrEP cost perceptions highlights the need for targeted outreach and messaging to improve PrEP uptake among at-risk populations who have not yet accessed it.

Adaptation of a Theory-Based Mobile App to Improve Access to HIV Prevention Services for Transgender Women in Malaysia: Focus Group Study.

Globally, transgender women have been disproportionately affected by the HIV epidemic, including in Malaysia, where an estimated 11% of transgender women are living with HIV. Available interventions designed specifically to meet transgender women's needs for HIV prevention are limited. Mobile health, particularly smartphone mobile apps, is an innovative and cost-effective strategy for reaching transgender women and delivering interventions to reduce HIV vulnerability. This study aims to adapt a theory-based mobile health HIV prevention smartphone app, HealthMindr, to meet the unique needs of transgender women in Malaysia. We conducted theater testing of the HealthMindr app with transgender women and key stakeholders and explored barriers to transgender women's uptake of HIV pre-exposure prophylaxis (PrEP). From February to April 2022, a total of 6 focus group (FG) sessions were conducted with 29 participants: 4 FG sessions with transgender women (n=18, 62%) and 2 FG sessions with stakeholders (n=11, 38%) providing HIV prevention services to transgender women in Malaysia. Barriers to PrEP uptake and gender-affirming care services among transgender women in Malaysia were explored. Participants were then introduced to the HealthMindr app and provided a comprehensive tour of the app's features and functions. Participants provided feedback on the app and on how existing features should be adapted to meet the needs of transgender women, as well as any features that should be removed or added. Each FG was digitally recorded and transcribed. Transcripts were coded inductively using Dedoose software (version 9.0.54; SocioCultural Research Consultants, LLC) and analyzed to identify and interpret emerging themes. Six subthemes related to PrEP barriers were found: stigma and discrimination, limited PrEP knowledge, high PrEP cost, accessibility concerns, alternative prevention methods, and perceived adverse effects. Participants suggested several recommendations regarding the attributes and app features that would be the most useful for transgender women in Malaysia. Adaptation and refinement of the app were related to the attributes of the app (user interface, security, customizable colors, themes, and avatars), feedback, and requests for additional mobile app functional (appointment booking, e-consultation, e-pharmacy, medicine tracker, mood tracker, resources, and service site locator) and communication (peer support group, live chat, and discussion forum) features. The results reveal that multifaceted barriers hinder PrEP uptake and use among transgender women in Malaysia. The findings also provide detailed recommendations for successfully adapting the HealthMindr app to the context of Malaysian transgender women, with a potential solution for delivering tailored HIV prevention, including PrEP, and increasing accessibility to gender-affirming care services.

Developing a Theory-Based Instrument for Pre-Exposure Prophylaxis (PrEP) Uptake in People of Color Using a Qualitative Approach.

There is a large disparity in Pre-exposure Prophylaxis (PrEP) utilization among communities of color compared to White Americans. There is also a lack of theory-based survey instruments to measure the underlying reasons for the disparity among communities of color. The purpose of this study was to create an instrument based on a qualitative approach involving community interviews. Semi-structured interviews guided by the Multi-theory Model (MTM) of health behavior change were performed in a sample of 12 members from communities of color. The analysis entailed a directed content analysis along the themes of MTM constructs to develop a survey instrument. The barriers to PrEP that emerged included the cost of PrEP, lack of protection from other sexually transmitted diseases, reduced trust between partners, and the stigma associated with PrEP. The perceived disadvantages included the potential cost of PrEP, partner mistrust when taking PrEP, discussion of sexual behaviors with a provider, and unclear process of acquiring the PrEP prescription. The results guided the development of a survey tool to further investigate aspects of cost, partner relations, stigma, reassurance of safety, and other factors. The tool can be used for future studies as part of guided interventions to increase PrEP uptake.

Access to PrEP and other sexual health services for cisgender women in the United States: a review of state policy and Medicaid expansion.

Pre-exposure prophylaxis (PrEP) has the potential to prevent new HIV infections, but it is unclear how state policies governing sexual and reproductive health services (SRH) impact access for cisgender women. The objective of this review is to identify barriers to PrEP access for cisgender women in the United States. Using the CDC Atlas Program, 20 states with the highest HIV incidence among cisgender women were included in this analysis. Through a search conducted in May-July 2022 of CDC, PrEPWatch.org, and other State Department and Insurance websites, Medicaid expansion status, pharmacist PrEP prescribing laws, financial support programs, and Traditional Medicaid coverage of PrEP, HIV testing, and emergency contraception were reviewed. Of the included states, nearly half did not expand Medicaid at the state level. Emergency contraception and HIV testing was covered under Traditional Medicaid for almost all included states, but insurance stipulations and eligibility requirements remain. Although PrEP is covered under all Traditional Medicaid plans, six states require pre-authorization. Three states have HIV testing mandates, four allow pharmacists to prescribe PrEP and six have financial support programs to cover the cost of PrEP. Medicaid expansion, pre-authorization requirements for PrEP prescriptions and emergency contraception, and limitations on pharmacist prescribing abilities were identified as barriers to SRH access for cisgender women. Medicaid expansion should be prioritized as an approach to expanding access to HIV prevention services at the state level.

Exploring the Effectiveness of Pre-Exposure Prophylaxis (PrEP) Use for HIV Prevention among High-Risk Populations

Addressing the global burden of HIV requires effective preventative measures that have been shown to have high efficacy rates. PrEP is one of the preventative measures that is effective in preventing HIV. Different clinical trials and population studies have shown PrEPto have an efficacy rate of 40% to 90% when it comes to preventing HIV. Due to its high efficacy, PrEPcan reduce new HIV infections populations considered to be high risk. However, for efficacy to be high, there is a need to increase medication adherence and address the existing barriers that limit uptake. Some of these barriers are lack of knowledge, inadequate access, stigma,lack of trust in service providers, low perception of HIV risk, cost, and fear of side effects. Addressing these barriers can increase PrEP uptake and help in reducing HIV’s risk among high-risk populations. Some of the measures that can be put in place to address these barriers are providing education and training, allocating enough resources, leveraging technology, lowering PrEP costs, increasing insurance coverage, and improving communication among the targeted population.

Factors Associated with the Awareness of and Willingness to Use HIV Pre-exposure Prophylaxis Among Gay, Bisexual, and Other Men Who Have Sex with Men, Baltimore, MD, 2017-2019.

Pre-exposure prophylaxis (PrEP) is an effective tool in protecting persons from acquiring HIV infection through sex or injection drug use. However, awareness and willingness to use PrEP among Black gay, bisexual, and other men who have sex with men (BMSM) remain suboptimal compared to White MSM (WMSM) in the United States. Our aims were to (1) assess the factors associated with PrEP awareness and willingness to use PrEP among MSM and (2) compare the PrEP perceptions among BMSM versus non-Black MSM. Data were drawn from two cross-sectional behavioral surveys in Baltimore, MD: Behavioral Surveillance Research (BESURE) conducted in 2017, and Safe Spaces 4 Sexual Health (SS4SH), conducted in 2018 and 2019. Descriptive statistics were used to summarize the study population. We used Poisson regression models to identify variables associated with awareness of PrEP and willingness to use PrEP. PrEP perceptions were assessed via 13 items scored on a 5-point Likert scale. Finally, we conducted a post-hoc exploratory bivariate analysis of the relationship between PrEP perception and willingness to use PrEP, stratified by race/ethnicity. A total of 261 MSM participated in this study. Many of the participants were aware of PrEP (75.1%). Factors associated with greater PrEP awareness included having greater than a high school education (aRR 1.22, 95% CI 1.04, 1.43); and earning more than $25,000 annually (aRR 1.24, 95% CI 1.08, 1.42). Participants who had received money in exchange for sex one or more times were less likely to be aware of PrEP (aRR 0.59, 95% CI 0.36, 0.95). More than half of the participants were willing to use PrEP (55.3%). In bivariate and multivariable analyses, demographic or behavioral characteristics were not significantly associated with willingness to use PrEP. Higher agreement with the following statements was associated with lower willingness to use PrEP: "Having to take a pill every day is difficult" (RR 0.89, 95% CI 0.82-0.97) and, "I am concerned about the side effects of PrEP" (RR 0.89, 95% CI 0.82-0.96), and "PrEP is for people who have riskier sex lives than I do" (RR 0.86, 95% CI 0.78-0.95). Conversely, higher willingness to use PrEP was associated with comfortable having sex without a condom (RR 1.11, 95% CI 1.02-1.21), less anxious about sex (RR 1.12, 95% CI 1.02-1.24), and my friends think that I should take PrEP (RR 1.19, 95% CI 1.07-1.32). We found BMSM compared to non-Black MSM had higher mean scores related to taking a daily pill (p = 0.041), concerns about side effects (p = 0.012), concerns about people thinking they had HIV (p = 0.001), concerns about the financial costs of PrEP (p = 0.038) and caution when dealing with healthcare organizations/medical mistrust (p = 0.019). Perceptions with a statistically significant lower score among BMSM versus non-Black MSM included statements such as, comfortable having sex without a condom (p = 0.003) and less anxious about sex (p < 0.001). We conclude HIV prevention strategies, programs, and interventions should be cognizant of PrEP perceptions that facilitate or hinder PrEP uptake in Baltimore City, MD.

Facilitators and barriers to community pharmacy PrEP delivery: a scoping review.

Pre-exposure prophylaxis (PrEP) is an effective medication to reduce the risk of acquiring HIV. PrEP is available free of charge in the UK from sexual health clinics. Expanding PrEP delivery to community pharmacies holds promise and aligns with UK government goals to eliminate new cases of HIV by 2030. The aim of this scoping review was to describe the existing evidence about the barriers to and facilitators of community pharmacy oral PrEP delivery, for pharmacists and pharmacy clients, as aligned with the Capacity Opportunity, Motivation Behaviour (COM-B) Model. Five bibliographic and five review databases were searched from inception to August 2023. Literature of any study design was included if it discussed barriers and facilitators of community pharmacy PrEP delivery. Trial registrations, protocols and news articles were excluded. A total of 649 records were identified, 73 full texts were reviewed and 56 met the inclusion criteria, predominantly from high-income/westernized settings. Most of the included literature was original research (55%), from the United States (77%) conducted during or after the year 2020 (63%). Barriers to PrEP delivery for pharmacists included lack of knowledge, training and skills (capability), not having the necessary facilities (opportunity), concern about the costs of PrEP and believing that PrEP use could lead to risk behaviours and sexually transmitted infections (motivation). Facilitators included staff training (capability), time, the right facilities (opportunity), believing PrEP could be a source of profit and could reduce new HIV acquisitions (motivation). For clients, barriers included a lack of PrEP awareness (capability), pharmacy facilities (opportunity) and not considering pharmacists as healthcare providers (motivation). Facilitators included awareness of PrEP and pharmacist's training to deliver it (capability), the accessibility of pharmacies (opportunity) and having an interest in PrEP (motivation). To effectively enhance oral PrEP delivery in UK community pharmacies, the identified barriers and facilitators should be explored for UK relevance, addressed and leveraged at the pharmacy team, client and care pathway level. By comprehensively considering all aspects of the COM-B framework, community pharmacies could become crucial providers in expanding PrEP accessibility, contributing significantly to HIV prevention efforts.

Estimating the Costs of PrEP (Pre-Exposure Prophylaxis) HIV among Men who Have Sex with Men (MSM) Population as Advanced Preventive Strategies: The Societal Perspective

Men who have sex with men (MSM) are the key population that dominates the new HIV incidence rate in Indonesia. WHO recommends the use of Pre-Exposure Prophylaxis (PrEP) HIV as an advanced preventive strategy. This study aimed to estimate the total cost of PrEP in one year from a societal perspective. Observational research with a retrospective approach was conducted on the MSM population in Solo Raya, Central Java, Indonesia. Data were collected through a questionnaire to get direct nonmedical and indirect cost data. Direct medical costs were estimated from the tariff regulations. The result showed that, from 50 MSM, the mean age was 26.78 years, 10% had comorbidity, 26% had a sexually transmitted infection (STI) history and 72% had high-risk sexual behavior. The average estimated cost of a PrEP per person was $328.44. Direct medical costs were the biggest proportion of the total estimated cost. From the sensitivity analysis, the total estimated cost was the most sensitive to risk factor parameters. The risk factors, which include STI history and high-risk sexual behavior, have the greatest influence on the total cost because of the increased number of visits. PrEP implementation must involve other promotional and preventive strategies to reduce risk factors.

Social, Structural, Behavioral, and Clinical Barriers Influencing Pre-exposure Prophylaxis (PrEP) Use Among Young Black Men Who Have Sex with Men in the South: A Qualitative Update to a 2016 Study.

Antiretroviral pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV. Despite its promise, PrEP use is low, especially among young Black men who have sex with men (YBMSM). The prevalence of HIV in Mississippi (MS) is among the highest in the United States, with the bulk of new infections occurring amongst YBMSM living in Jackson, MS. We recruited 20 PrEP-eligible YBMSM and 10 clinic staff from MS health clinics between October 2021 and April 2022. Data were collected remotely using in-depth interviews and a brief survey, which lasted approximately 45-60min. Interview content included PrEP knowledge/experiences, HIV risk perception, and PrEP use barriers and facilitators. Qualitative data were coded then organized using NVivo. Using thematic analysis methodology, data were assessed for current barriers to PrEP use. An array of barriers were identified by participants. Barriers included structural factors (cost of PrEP, lack of discreet clinics, time commitment, competing interests); social factors (unaware of HIV risk, stigma and homophobia, fear that partners would find out about PrEP use, not knowing anyone on PrEP); behavioral factors (sexual risk factors, denial, less priority for prevention vs treatment); and clinical factors (misunderstood side effects, fear PrEP won't work). Significant barriers to PrEP use among YBMSM stem from structural, social, behavioral, and clinical factors. These results will inform intervention efforts tailored to mitigate barriers and improve PrEP uptake among YBMSM in the southern United States.

Daily Oral HIV Pre-exposure Prophylaxis Among Young Men Who Have Sex With Men in the United States: Cost-saving at Generic Drug Price.

Adherence and retention concerns raise questions about the effectiveness and cost-effectiveness of oral HIV pre-exposure prophylaxis (PrEP) in young men who have sex with men (YMSM). Using an adolescent-focused simulation model, we compared annual HIV screening alone with tenofovir disoproxil fumarate/emtricitabine-based oral PrEP with every 3-month HIV screening in YMSM (aged 15-24) at increased risk of HIV. Data derived from published sources included: age-stratified HIV incidence/100 person-years (PY) on- or off-PrEP (0.6-10.1 or 0.4-6.4), PrEP retention at 6 years (28%), transmissions by HIV RNA level (0.0-78.4/100PY) and annual costs of antiretroviral therapy ($32 000-69 000), HIV care ($3100-34 600), and PrEP program/generic drug ($900/360). Outcomes included transmissions (percent of cohort infected), quality-adjusted life-years (QALYs), costs ($), and incremental cost-effectiveness ratios ($/QALY). We explored the sensitivity of findings to variation in HIV incidence and drug prices. Compared with annual screening alone, PrEP would increase QALYs (9.58 to 9.67), reduce new infections (37% to 30%), and decrease costs (by $5000) over 10 years. PrEP would remain cost-saving for HIV incidence off-PrEP ≥5.1/100PY or annual PrEP price ≤$1200. Over a lifetime horizon, PrEP would be cost-saving for HIV incidence off-PrEP ≥1.0/100PY, across all retention assumptions examined. PrEP would not be cost-effective at HIV incidence ≤0.1/100PY, regardless of drug price, due to programmatic costs. In US YMSM at increased risk of HIV, generic oral PrEP and every-3-month screening would be cost-saving compared with annual screening alone, even with high discontinuation and low adherence, over a range of HIV incidences.

Identifying HIV PrEP Attributes to Increase PrEP Use Among Different Groups of Gay, Bisexual, and Other Men Who Have Sex with Men: A Latent Class Analysis of a Discrete Choice Experiment.

Daily pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV among gay, bisexual, and other men who have sex with men (GBMSM), although uptake remains suboptimal. By identifying the features of PrEP that appeal to various subgroups of GBMSM, this study aimed to improve PrEP uptake by examining preferences for PrEP use. Adults ≥ 18years old in six New England states completed an online discrete choice experiment survey. A latent class analysis (LCA) was conducted to identify groups of GBMSM based on four attributes of choices for PrEP (cost, time, side effects, and mode of administration). Multinominal logistic regression was conducted to compare the association between sociodemographic and behavioral characteristics and class memberships. Data from 675 GBMSM were analyzed. A 3-Class model was selected as the best fit model. Class 1 (47.7% of individuals) was identified as having "no specific preferences". Class 2 (18.5% of individuals) were "Cost- and time-conscious" and were significantly more likely to be older, have prior sexually transmitted infection (STI) testing, have low household income, private insurance, and have extreme concerns about HIV risk than those with no specific preference (Class 1). Finally, Class 3 (34.1% of individuals) were "Side effects-conscious" and were more likely to have low income, private insurance, and have moderate and extreme concerns about HIV risk than those with no specific preference (Class 1). Findings indicate that outreach to GBMSM who have never used PrEP should emphasize low cost and short travel times to increase potential PrEP use.

Cost-effectiveness analysis of HIV pre-exposure prophylaxis in Japan

BackgroundWhile global efforts have been made to prevent transmission of HIV, the epidemic persists. Men who have sex with men (MSM) are at high risk of infection. Despite evidence of its cost-effectiveness in other jurisdictions, pre-exposure prophylaxis (PrEP) for MSM is neither approved nor reimbursed in Japan.MethodThe cost-effectiveness analysis compared the use of once daily PrEP versus no PrEP among MSM over a 30-year time horizon from a national healthcare perspective. Epidemiological estimates for each of the 47 prefectures informed the model. Costs included HIV/AIDS treatment, HIV and testing for sexually transmitted infections, monitoring tests and consults, and hospitalization costs. Analyses included health and cost outcomes, as well as the incremental cost-effectiveness ratio (ICER) reported as the cost per quality-adjusted life year (QALY) for all of Japan and each prefecture. Sensitivity analyses were performed.FindingsThe estimated proportion of HIV infections prevented with the use of PrEP ranged from 48% to 69% across Japan, over the time horizon. Cost savings due to lower monitoring costs and general medical costs were observed. Assuming 100% coverage, for Japan overall, daily use of PrEP costs less and was more effective; daily use of PrEP was cost-effective at a willingness to pay threshold of ¥5,000,000 per QALY in 32 of the 47 prefectures. Sensitivity analyses found that the ICER was most sensitive to the cost of PrEP.InterpretationCompared to no PrEP use, once daily PrEP is a cost-effective strategy in Japanese MSM, reducing the clinical and economic burden associated with HIV.

PrEP and HIV prevention decision-making among social network members of women who have experienced incarceration: a qualitative study

ABSTRACT Incarceration and HIV are a syndemic for US women, yet very few women who have experienced incarceration use pre-exposure prophylaxis (PrEP) for HIV. We conducted semi-structured interviews with 32 participants recruited by women who have experienced incarceration from their social networks, informed by the modified social ecological model for PrEP. Emergent themes from the interviews included individual-level (low personal HIV risk assessment, personal responsibility for HIV prevention, and decisions in addiction versus recovery), network-level (influential sex partners and the importance of trust, supportive treatment peers, and high-risk but indifferent drug use networks), community-level (stigma, and mitigation of stigma in supportive substance use disorder treatment environments), and public policy-level (incarceration and PrEP cost and access) determinants. PrEP interventions for women who have experienced incarceration and their networks will need to incorporate contingency planning into HIV risk assessment, navigate complex network dynamics, and be situated in trusted contexts to address structural barriers.

The early-stage comprehensive costs of routine PrEP implementation and scale-up in Zambia.

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention option, but cost-effectiveness is sensitive to implementation and program costs. Studies indicate that, in addition to direct delivery cost, PrEP provision requires substantial demand creation and client support to encourage PrEP initiation and persistence. We estimated the cost of providing PrEP in Zambia through different PrEP delivery models. Taking a guidelines-based approach for visits, labs and drugs, we estimated the annual cost of providing PrEP per client for five delivery models: one focused on key populations (men-who-have-sex-with-men (MSM) and female sex workers (FSW), one on adolescent girls and young women (AGYW), and three integrated programs (operated within HIV counselling and testing services at primary healthcare centres). Program start-up and support costs were based on program expenditure data and number of PrEP sites and clients in 2018. PrEP clinic visit costs were based on micro-costing at two PrEP delivery sites (2018 USD). Costs are presented in 2018 prices and inflated to 2021 prices. The annual cost/PrEP client varied by service delivery model, from $394 (AGYW) to $655 (integrated model). Cost differences were driven largely by client volume, which impacted the relative costs of program support and technical assistance assigned to each PrEP client. Direct service delivery costs ranged narrowly from $205-212/PrEP-client and were a key component in the cost of PrEP, representing 35-65% of total costs. The results show that, even when integrated into full service delivery models, accessing vulnerable, marginalised populations at substantial risk of HIV infection is likely to cost more than previously estimated due to the programmatic costs involved in community sensitization and client support. Improved data on individual client resource usage and outcomes is required to get a better understanding of the true resource utilization, expected outcomes and annual costs of different PrEP service delivery programs in Zambia.

Paying for PrEP: A qualitative study of cost factors that impact pre-exposure prophylaxis uptake in the US.

Concerns about the actual and perceived costs of pre-exposure prophylaxis (PrEP) continue to be a major barrier to uptake among gay, bisexual and men who have sex with men (GBMSM) in the United States. We conducted semi-structured interviews with 25 GBMSM who presented for routine health care at a STD clinic in the northeastern United States. The cohort included GBMSM who were or were not currently taking PrEP and represented varied health care coverage and financial resources. We used a structured coding scheme to analyze transcripts and identify themes relevant to cost factors. Participants shared their perspectives about PrEP and their experiences with accessing and paying for PrEP. Our findings suggest that health care coverage or financial assistance were essential to PrEP access but were not easily accessible to all people and did not always cover all costs. Therefore, paying for PrEP had to be balanced with other life expenses. Participants had multiple sources for information about PrEP cost and assistance from clinic and pharmacy staff helped reduce burden and resolve difficulties. Addressing gaps in health care coverage, providing financial support, and improving the enrollment process in a financial assistance program may improve PrEP uptake.

Out-of-pocket Expenses and Time Spent on Clinic Visits Among HIV Pre-exposure Prophylaxis Users and Other Clinic Attendees in Eswatini

User costs constitute a barrier to the uptake of HIV pre-exposure prophylaxis (PrEP), but their magnitude appears rarely assessed. In this prospective observational study, we assessed self-reported out-of-pocket expenses (OOPE) and time spent on clinic visits during a PrEP demonstration project in Eswatini. At six public primary care clinics, 240 PrEP users and other clinic attendees were interviewed after a clinic visit. Among the 79.2% of clinic attendees reporting any medical OOPE (e.g., expenses for consultations or drugs) and/or non-medical OOPE (e.g., expenses for transport, food, or phone use), the median total OOPE was $1.36 (IQR 0.91–1.96). Non-medical OOPE occurred mostly due to transport expenses. The median travel time for a clinic visit was 1.0 h (IQR 0.67–2.0). The median time spent in the clinic was 2.0 h (IQR 1.15–3.0). The median opportunity cost of a clinic visit was $7.54 (IQR 5.42–11) when valuing time spent on a clinic visit with Eswatini’s per-capita gross domestic product. Our findings can guide measures to reduce the user costs of PrEP in Eswatini and other contexts in which oral PrEP is provided through health care facilities.

HIV pre-exposure prophylaxis (PrEP) should be free across Canada to those meeting evidence-based guidelines

HIV pre-exposure prophylaxis (PrEP) should be free across Canada for all those who meet evidence-based guidelines. PrEP is a highly effective tool for preventing HIV acquisition that has been approved for use in Canada since 2016. However, without public drug plans or private insurance, generic PrEP costs approximately $200 to $250 CAD monthly. Current PrEP programs across Canada are a confusing patchwork system with variability in coverage and prohibitive co-payments, making PrEP too expensive for many equity-deserving groups. However, publicly funded PrEP programs are demonstrated to be cost-effective and even cost-saving by reducing the long-term healthcare expenditures associated with managing HIV. PrEP is not just an individual-level clinical tool. It is a public health intervention. Alongside “treatment as prevention,” PrEP is an important population-level strategy for eliminating new HIV infections in Canada and can play a role in helping to address complex health inequities affecting communities highly affected by HIV. Navigating drug coverage for patients consumes time and resources among healthcare providers that could be spent helping to improve other social determinants of health. Affordability will remain the foremost barrier to PrEP access until PrEP is made free to all those who meet evidence-based guidelines.

Estimating the budget impact of adopting tenofovir/emtricitabine for pre-exposure prophylaxis of HIV in the public health sector in Namibia (2021 – 2023)

Although Namibia started implementing pre-exposure prophylaxis (PrEP) of Human Immunodeficiency Virus (HIV) in 2016, no study to determine its budget impact has been conducted. This study, therefore, aimed to estimate the budget impact of adopting tenofovir/emtricitabine for PrEP of HIV for all eligible people in the public health sector in Namibia from 2021 to 2023. A country-specific model was developed for this budget impact analysis (BIA). PrEP has targeted all eligible people in Namibia who receive health services from the public sector. It was assumed that the adherence rate was 75% and PrEP effectiveness 60% in this study. Costs used in this study were taken from a study that included Namibian costs. The BIA suggests that adopting PrEP may be cost saving as US$104 823, US$143 620, and US$182 452 of additional HIV care costs will potentially be saved in 2021, 2022, and 2023, respectively. Cost savings rely on high adherence rates, high PrEP effectiveness rates, low PrEP costs, and a small number of people living with HIV (PLHIV). Further economic analysis could aid decision-making in Namibia, both to stress test assumptions in the BIA and conduct cost-effectiveness analysis to estimate the value for money of PrEP.