The Cost-effectiveness of Human Immunodeficiency Virus (HIV) Preexposure Prophylaxis and HIV Testing Strategies in High-risk Groups in India

• Published in: Clinical infectious diseases Vol. 70; no. 4; pp. 633 - 642
• Main Authors: Kazemian, Pooyan, Costantini, Sydney, Kumarasamy, Nagalingeswaran, Paltiel, A David, Mayer, Kenneth H, Chandhiok, Nomita, Walensky, Rochelle P, Freedberg, Kenneth A
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 03.02.2020
• Subjects: and Commentaries; Anti-HIV Agents - therapeutic use; Cost-Benefit Analysis; HIV; HIV Infections - diagnosis; HIV Infections - epidemiology; HIV Infections - prevention & control; HIV Testing; Homosexuality, Male; Humans; India - epidemiology; Male; Pre-Exposure Prophylaxis; Sexual and Gender Minorities; India; cost-effectiveness; PrEP; HIV; testing; India
• ISSN: 1058-4838; 1537-6591
• DOI: 10.1093/cid/ciz249

Abstract Background The human immunodeficiency virus (HIV) epidemic in India is concentrated among 3.1 million men who have sex with men (MSM) and 1.1 million people who inject drugs (PWID), with a mean incidence of 0.9–1.4 per 100 person-years. We examined the cost-effectiveness of both preexposure prophylaxis (PrEP) and HIV testing strategies for MSM and PWID in India. Methods We populated an HIV microsimulation model with India-specific data and projected clinical and economic outcomes of 7 strategies for MSM/PWID, including status quo; a 1-time HIV test; routine HIV testing every 3, 6, or 12 months; and PrEP with HIV testing every 3 or 6 months. We used a willingness-to-pay threshold of US$1950, the 2017 Indian per capita gross domestic product, to define cost-effectiveness. Results HIV testing alone increased life expectancy by 0.07–0.30 years in MSM; PrEP added approximately 0.90 life-years to status quo. Results were similar in PWID. PrEP with 6-month testing was cost-effective for both MSM (incremental cost-effectiveness ratio [ICER], $1000/year of life saved [YLS]) and PWID (ICER, $500/YLS). Results were most sensitive to HIV incidence. PrEP with 6-month testing would increase HIV-related expenditures by US$708 million (MSM) and US$218 million (PWID) over 5 years compared to status quo. Conclusions While the World Health Organization recommends PrEP with quarterly HIV testing, our analysis identifies PrEP with semiannual testing as the cost-effective HIV prevention strategy for Indian MSM and PWID. Since nationwide scale-up would require a substantial fiscal investment, areas of highest HIV incidence may be the appropriate initial targets for PrEP scale-up. In India, preexposure prophylaxis for Human Immunodeficieny Virus (HIV) combined with HIV testing every 6 months is a cost-effective strategy for men who have sex with men and people who inject drugs over a lifetime horizon.