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

• Published in: Clinical infectious diseases Vol. 78; no. 2; p. 402
• Main Authors: Amick, Alyssa K, Eskibozkurt, G Ege, Hosek, Sybil G, Flanagan, Clare F, Landovitz, Raphael J, Jin, Elena Y, Wilson, Craig M, Freedberg, Kenneth A, Weinstein, Milton C, Kazemian, Pooyan, Paltiel, A David, Ciaranello, Andrea L, Neilan, Anne M
• Format: Journal Article
• Language: English
• Published: United States 17.02.2024
• Subjects: Adolescent; Anti-HIV Agents - therapeutic use; Cost-Benefit Analysis; Drugs, Generic; HIV Infections - drug therapy; HIV Infections - epidemiology; HIV Infections - prevention & control; Homosexuality, Male; Humans; Male; Pre-Exposure Prophylaxis; Sexual and Gender Minorities; United States - epidemiology; United States; cost-effectiveness; pre-exposure prophylaxis; HIV; youth; YMSM
• ISSN: 1537-6591
• DOI: 10.1093/cid/ciad566

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.