Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) studies 110/113 found oral tenofovir disoproxil fumarate/emtricitabine (F/TDF) HIV pre-exposure prophylaxis (PrEP) to be safe and feasible among young men who have sex with men (YMSM, ages 13-24). However, questions remain about the cost-effectiveness of PrEP in this population with low adherence and retention.
We used a simulation model to compare annual HIV screening alone to PrEP with quarterly screening among YMSM at high risk of HIV acquisition. Data derived from published sources included: age-stratified HIV incidence/100PY [off-PrEP (15-17y: 10.2, 18-34y: 5.2, 35-44y: 5.0, 45-54y: 3.2, ?55y: 0.7); on-PrEP (15-17y: 6.5, 18-34y: 3.3, 35-44y: 3.1, 45-54y: 2.0, ?55y: 0.5]) and PrEP retention at 10 years (11%). We stratified primary onward HIV transmissions by HIV RNA level (0.0-78.4/100PY). Annual costs included antiretroviral therapy (ART, $31,000), HIV care ($300-$1,200), and PrEP program and drug ($430+$360). Projected outcomes included HIV transmissions, quality-adjusted life years (QALY), costs, and incremental cost-effectiveness ratios (ICER, $/QALY) over 10-year, 20-year, and lifetime horizons. We explored the sensitivity of our findings to annual costs of branded PrEP drug ($9,100) and ART ($0-$47,500), and HIV incidence (as low as 0.01/100PY, i.e., general population including those not meeting PrEP eligibility criteria).
Compared to annual screening, PrEP would increase QALYs (8.37 to 8.42), reduce new HIV infections (40% to 35%), and decrease costs (by $14,000) over 10 years among YMSM at high-risk of HIV infection. At a 10-year horizon, PrEP would be cost saving at HIV incidences off-PrEP ?0.2/100PY and ART cost ?$1,200. At the lifetime horizon, PrEP would be cost saving even if ART were free or if HIV incidence off-PrEP were ?0.4/100PY. At incidences as low as 0.01/100PY, the ICER would be $600,000/QALY over a lifetime. With branded PrEP drug price, PrEP would increase costs by $15,000 over a 10-year horizon resulting in an ICER of $347,000/QALY ($51,000/QALY over 20 years); at this price point, PrEP would be cost saving over a lifetime horizon.
In a population of US YMSM at high risk of HIV acquisition, PrEP compared to annual HIV screening alone would be cost saving, despite high discontinuation rates and poor adherence. At generic PrEP prices, PrEP would be cost saving over a lifetime even with free ART or HIV incidences lower than observed among YMSM in ATN 110/113.