Abstract Body

While PrEP efficacy among men who have sex with men (MSM) and transgender women (TW) has been demonstrated, a key step to inform its national scale up in low and middle income countries is to evaluate its impact and cost effectiveness under real world conditions. From 2018 to 2020, the ImPrEP demonstration project enrolled 1954 MSM and 275 TW in public sexual health clinics and an NGO in six cities in Peru, providing rich data to inform an HIV epidemic and economic model of PrEP impact.

We used data from the ImPrEP project to perform a micro-costing analysis of adding PrEP to services provided by public sexual health clinics. This included ongoing costs of ARV drugs, laboratory tests, transport and personnel, as well as start-up costs related to equipment and infrastructure. We informed our dynamic model which explicitly represents transmission among 4 main groups: gay-identified MSM, bisexual/heterosexual-identified MSM, male sex workers (MSW) and TW with ImPrEP data on PrEP uptake, retention and adherence by group to estimate impact and cost-effectiveness of PrEP scale-up on reducing HIV incidence between 2022-2030.

The cost of one year of PrEP provision was estimated at USD $1,065, with a third of these costs attributable to ARV drugs ($75/person/year) and laboratory testing. Of the participants, 59% identified as gay, 14% identified as heterosexual/bisexual, 14% were MSW and 13% were TW. Assuming observed patterns of PrEP uptake, retention and adherence by group between 2022-2030, scaling up PrEP to 20% of the MSM/TW population, could avert 26% (95%CI: 22%-32%) of new HIV infections. Impact would be highest among TW with 46% (95%CI: 34%-60%) of new infections averted. The cost per DALY averted would be of $6,186 (95%CI: $3,192-$11,387). This is within the WHO threshold of 1 GDP/capita ($6,941) and the Peru specific threshold estimated by Woods ($7747), but above that estimated by Ochaleck ($1300), which is more stringent as it is based on the correlation between changes in health expenditure and in mortality/morbidity in Peru.

PrEP implementation by the Ministry of Health (MoH) in Peru at a feasible coverage of 20% would significantly reduce HIV incidence among MSM and TW and would be cost-effective under most thresholds. However, enhancing retention and adherence would improve efficiency. Additionally, some costs would benefit from MoH economies of scale. Importantly, such PrEP program would reduce HIV disparities among TW.