Background
Oral pre-exposure prophylaxis (oral PrEP) has long been part of the HIV prevention portfolio in Zimbabwe. The introduction of long-acting, injectable PrEP (LA PrEP) in 2022 and the dapivirine vaginal ring (ring PrEP) in 2023 have the potential to increase PrEP uptake and further reduce HIV incidence in Zimbabwe. However, the impact and optimal implementation strategy of ring PrEP and LA PrEP are unclear. We aim to identify the cost-effectiveness of different implementation strategies using the three types of PrEP in Zimbabwe.
Methods
Using a validated HIV compartmental transmission model in Zimbabwe, we compared 3,136 permutations of PrEP implementation strategies. We compared three types of PrEP (oral, LA, ring) across various coverage levels (10%, 50%, 70%) and targeted different groups, including adolescent girls and young women ages 15-24 (AGYW), adolescent boys and young men ages 15-24, men aged 25 to 34, and high-risk groups such as female sex workers (FSW), men who have sex with men (MSM), people with alcohol use disorder, and people with major depressive disorder. Cost, effectiveness, retention, and coverage inputs were based on the literature, expert opinion, and national surveillance results. Outcomes were infections averted, quality-adjusted life-years (QALYs) gained, cost per infection averted, and cost per QALY gained.
Results
LA PrEP is more cost-effective than oral and ring PrEP. Implementing LA PrEP for FSW at 70% coverage level is the most cost-effective strategy, averting 10895 additional infections and adding 6711 additional QALYs through 2030. This strategy costs $11.8 million per year and has an incremental cost-effectiveness ratio (ICER) of $1081/infection averted or $1545/QALY, when compared to the baseline implementation of oral PrEP at 10% coverage. Targeting FSW for LA PrEP at various coverage levels has similar ICERs and is more cost-effective than other common HIV prevention programs, such as additionally scaling-up index tracing, differentiated care, voluntary medical male circumcision, HIV self-testing, and defaulter tracing. However, when LA PrEP is targeted to other risk groups beyond FSW, LA PrEP becomes less cost-effective than other prevention programs.
Conclusions
Targeting high-risk populations like FSW with LA PrEP is the most cost-effective PrEP implementation strategy and contributes to Zimbabwe’s Ending the HIV Epidemic 2030 goal.
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