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A Cost-Effectiveness Analysis Of Pre-Exposure Prophylaxis For The Prevention Of HIV Among Los Angeles County Men Who Have Sex With Men - Editorial
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EDITORIAL - Can We Afford to Control the HIV Epidemic with Antiretrovirals? Can We Afford Not to Do So?
....below following Editorial is Cost effectiveness study

Kenneth H. Mayer, Douglas S. Krakower
In the current issue of Clinical Infectious Diseases, Drabo and associates found that for MSM in Los Angeles county that testing every 4 years and immediate initiation of treatment ("test and treat") was the most cost-effective, being less than $20,000 per quality-adjusted life-year (QALY) [11]. Scenarios with HIV testing as frequently as every 6 months followed by immediate treatment were also highly cost-effective. This is not surprising, given that the medication increases individuals' life expectancies and renders them less infectious. What also emerged from their study was that providing PrEP for the highest risk HIV-uninfected MSM in addition to a test and treat strategy would increase the QALY to $27,863 per year in the most cost effective scenario, but that this would lead to further decreases in the number of new HIV infections. Their simulations are helpful in helping policy makers and public health authorities think through optimal strategies for HIV epidemic control, but have to be anchored in the real world of an ongoing domestic and international HIV epidemic.
The rationale for early and prompt treatment is clear cut, but currently, 15% of HIV-infected Americans are unaware of their HIV status [12], and close to 50,000 new infections occur each year [13], so any test and treat strategy still needs to focus on wider expansion of testing.
The rationale for early and prompt treatment is clear cut, but currently, 15% of HIV-infected Americans are unaware of their HIV status [12], and close to 50,000 new infections occur each year [13], so any test and treat strategy still needs to focus on wider expansion of testing. Although the U.S. Preventative Service Task Force (USPSTF) has recommended testing all American between the ages of 15 and 65 at least once in their lifetime, and more frequent testing for those at increased risk of HIV [14], many Americans remain untested, or not tested repeatedly if they are high risk. In addition, although 85% of HIV-infected Americans are aware of their status, only approximately 30% are virologically suppressed with antiretrovirals [12]. This means that there are more than 500,000 Americans who are potentially infectious to their partners. Thus, test and treat strategies alone are not sufficient, particularly because HIV treatment entails a lifelong commitment to therapy, requiring ongoing engagement in care to maintain virology suppression.
The reality that virologic suppression of all HIV-infected people is not iminent, provides the rationale for the addition of PrEP. However, with the current cost of PrEP medication and follow-up exceeding $10,000 per year, its use must be judicious and selective.
Therefore candidates for PrEP should be among those at highest risk for HIV infection. However, many of these individuals may not be routinely engaged in care because they are otherwise healthy, and may come from socially marginalized populations, not perceiving healthcare settings as culturally competent and congenial. It is incumbent upon clinical providers to become familiar with how to best make individuals from sexual and gender minority populations and those who use injection drugs feel comfortable with their care and to be able to elicit histories of their potential risk-taking behavior. Only when individuals are comfortable in delineating their potential HIV exposures can PrEP be considered. PrEP is not a "wholesale" intervention, but its selective use in discreet populations at highest risk for HIV, particularly urban men who have sex with men from racial and ethnic minority communities, can be clearly cost-effective as demonstrated in the Drabo et al article.
Many HIV-infected individuals, as well as those at increased risk, may have social, structural, and behavioral issues that need to be addressed if the therapeutic and prophylactic use of antiretroviral medication is to be effective. These challenges include unstable housing, substance addictions, and depression, which may limit their ability to be highly adherent [20]. Thus, effective use of antiretroviral treatment in controlling the HIV epidemic invariably involves addressing these factors. For PrEP users, it is conceivable that if the factors that potentiate their risk are addressed, their PrEP course may be limited, and they could discontinue PrEP. Although antiretrovirals are not a panacea, their judicious use in a comprehensive program that addresses the full medical and behavioral health needs of those who are HIV-infected or affected can contribute to a net result that will halt the further spread of HIV.
A Cost-Effectiveness Analysis Of Pre-Exposure Prophylaxis For The Prevention Of HIV Among Los Angeles County Men Who Have Sex With Men
Clinical Infectious Diseases Advance Access published August 23, 2016
Substantial gaps remain in understanding the trade-offs between the costs and benefits of choosing alternative HIV prevention strategies, including Test-and-Treat (expanded HIV testing combined with immediate treatment), and PrEP (initiation of pre-exposure prophylaxis [PrEP] by high risk uninfected individuals) strategies.
METHODS. We develop a mathematical epidemiological model to simulate HIV incidence among men residing in Los Angeles County, CA, aged 15-65 year, who have sex with men. We combine these incidence data with an economic model to estimate the discounted cost, effectiveness (quality-adjusted life years [QALYS]) and incremental cost-effectiveness ratios (ICERs) of various HIV prevention strategies using a societal perspective and a lifetime horizon.
RESULTS. PrEP and Test-and-Treat yield the largest reductions in HIV incidence, and are highly cost-effective ($27863/QALY and $19302/QALY, respectively) relative to Status Quo and at a US willingness-to-pay threshold of $150000/QALY saved. Status Quo and twelve Test-and-Treat and PrEP strategies determine the frontier for efficient decisions. More aggressive strategies are costlier, but more effective, albeit with diminishing returns. The relative effectiveness of PrEP is sensitive to the initial HIV prevalence rate, PrEP and ART adherence and initiation rates, the probabilities of HIV transmission, and the rates of sexual partner mixing.
CONCLUSIONS. PrEP and Test-and-Treat offer cost-effective alternatives to the Status Quo. The success of these strategies depends on ART and PrEP adherence and initiation rates. The lack of evidence on adherence behaviors toward PrEP, therefore, warrants further studies.
Our results support prior findings that PrEP can be cost-effective in highly concentrated epidemic settings even when a richer set of alternate HIV policies are evaluated [38]. However, the optimal strategy depends on the costs society is willing to incur for HIV prevention. With constrained budgets Test-and-Treat is the optimal policy and with less constrained budgets Test-and-Treat combined with PrEP is the optimal policy. Overall these results help policymakers and public health officials choose the optimal HIV prevention strategy given their budget constraints. The results also support the recent LAC, WHO and US officials' endorsement of PrEP, as well as New York Governor Cuomo's call for a statewide adoption of the strategy [39]. However, our results also suggest that even the most aggressive cost-effective HIV prevention strategy is unlikely to eliminate the HIV epidemic. The success of these strategies depends on the uptake of and adherence to treatment. The lack of evidence on behavioral responses to PrEP, therefore, warrants further studies.
Our study suggests that PrEP and Test-and-Treat constitute cost-effective HIV prevention alternatives to SQ, and that relative to SQ, the most efficient PrEP strategies could cost $27863-$37181/QALY gained, whereas the Test-and-Treat strategies could cost $19302-$24544/QALY gained. These results are consistent with the Desai et al [36] finding that PrEP for the New York City high-risk MSM would cost $32000/QALY. They differ, however, from the Juusola et al [17] estimates of $50000/QALY in high-risk MSM. They also differ from the Koppenhaver et al [18] estimates of $353739 and $570273 per QALY gained among highly adherent MSM (i.e. taking >90% of PrEP doses [pill counts]) and in the overall population, respectively, at universal PrEP coverage. These discrepancies likely owe to differences in modeling assumptions and epidemic trends in the study settings. For example, initial HIV prevalence in our study (LAC MSM; 24.1% in 2010 and 24.6% in 2013) is nearly double that in Juusola et al (US MSM; 12.3% in 2010). Indeed, in sensitivity analysis, these differences account for a significant portion of the discrepancy between the ICERs of the two studies (Figure S8 and Table S24). Likewise, differences in initial HIV prevalence (17.5% vs 24.6%) and the assumptions about PrEP coverage (universal vs 10% coverage) likely explain the discrepancy between the ICERs in Koppenhaver et al and our study.

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