Cost-Effectiveness of Long-Acting Injectable HIV Preexposure Prophylaxis in the United States : A Cost-Effectiveness Analysis

• Published in: Annals of internal medicine Vol. 175; no. 4; p. 479
• Main Authors: Neilan, Anne M, Landovitz, Raphael J, Le, Mylinh H, Grinsztejn, Beatriz, Freedberg, Kenneth A, McCauley, Marybeth, Wattananimitgul, Nattanicha, Cohen, Myron S, Ciaranello, Andrea L, Clement, Meredith E, Reddy, Krishna P, Hyle, Emily P, Paltiel, A David, Walensky, Rochelle P
• Format: Journal Article
• Language: English
• Published: United States 01.04.2022
• Subjects: Anti-HIV Agents - therapeutic use; Child; Cost-Benefit Analysis; Drugs, Generic; Emtricitabine - therapeutic use; Female; HIV Infections - drug therapy; Homosexuality, Male; Humans; Male; Pre-Exposure Prophylaxis; Sexual and Gender Minorities; Tenofovir - therapeutic use; United States; United States
• ISSN: 1539-3704
• DOI: 10.7326/M21-1548

The HIV Prevention Trials Network (HPTN) 083 trial demonstrated the superiority of long-acting injectable cabotegravir (CAB-LA) compared with oral emtricitabine-tenofovir disoproxil fumarate (F/TDF) for HIV preexposure prophylaxis (PrEP). To identify the maximum price premium (that is, greatest possible price differential) that society should be willing to accept for the additional benefits of CAB-LA over tenofovir-based PrEP among men who have sex with men and transgender women (MSM/TGW) in the United States. Simulation, cost-effectiveness analysis. Trial and published data, including estimated HIV incidence (5.32, 1.33, and 0.26 per 100 person-years for off PrEP, generic F/TDF and branded emtricitabine-tenofovir alafenamide (F/TAF), and CAB-LA, respectively); 28% 6-year PrEP retention. Annual base-case drug costs: $360 and $16 800 for generic F/TDF and branded F/TAF. Fewer side effects with branded F/TAF versus generic F/TDF were assumed. 476 700 MSM/TGW at very high risk for HIV (VHR). 10 years. Health care system. CAB-LA versus generic F/TDF or branded F/TAF for HIV PrEP. Primary transmissions, quality-adjusted life-years (QALYs), costs (2020 U.S. dollars), incremental cost-effectiveness ratios (ICERs; U.S. dollars per QALY), maximum price premium for CAB-LA versus tenofovir-based PrEP. Compared with generic F/TDF (or branded F/TAF), CAB-LA increased life expectancy by 28 000 QALYs (26 000 QALYs) among those at VHR. Branded F/TAF cost more per QALY gained than generic F/TDF compared with no PrEP. At 10 years, CAB-LA could achieve an ICER of at most $100 000 per QALY compared with generic F/TDF at a maximum price premium of $3700 per year over generic F/TDF (CAB-LA price <$4100 per year). In a PrEP-eligible population at high risk for HIV, rather than at VHR ( = 1 906 800; off PrEP incidence: 1.54 per 100 person-years), CAB-LA could achieve an ICER of at most $100 000 per QALY versus generic F/TDF at a maximum price premium of $1100 per year over generic F/TDF (CAB-LA price <$1500 per year). Uncertain clinical and economic benefits of averting future transmissions. Effective oral PrEP limits the additional price society should be willing to pay for CAB-LA. FHI 360; National Institute of Child Health and Human Development; National Institute of Allergy and Infectious Diseases; National Heart, Lung, and Blood Institute; National Institute on Drug Abuse; the Reich HIV Scholar Award; and the Steve and Deborah Gorlin MGH Research Scholars Award.