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Preventing 1 Infection With As-Needed PrEP
Costs 3 to 4 Times More Than HIV Therapy
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21st International AIDS Conference (AIDS 2016), July 18-22, 2016, Durban, South Africa
IAC: Efficacy of "On Demand" PrEP in the ANRS IPERGAY Open-Label Extension Study - (07/20/14)
Mark Mascolini
Preventing one new HIV infection with tenofovir/emtricitabine (TDF/FTC) before- and after-sex preexposure prophylaxis (PrEP) would cost an estimated 3 to 4 times more yearly than HIV therapy, according to an analysis by IPERGAY investigators [1]. But the researchers noted that this cost analysis does not consider other potential benefits of as-needed PrEP.
Whereas other TDF/FTC trials asked participants to take their PrEP pill daily, IPERGAY asked 400 men who have sex with men (MSM) in France and Canada to take two TDF/FTC tablets (or placebo) 2 to 24 hours before sex, one tablet 24 hours later, and one tablet 48 hours after the first dose. After a median 9.3 months of follow-up, PrEP lowered HIV acquisition risk 86% (P = 0.002) [2]. The IPERGAY team figured that 18 people have to be treated for 1 year to prevent 1 HIV infection with this strategy.
As-needed PrEP will certainly cost less than daily PrEP (unless a person has risky sex almost every day). To calculate costs of PrEP with the IPERGAY before-and-after dosing schedule, the investigators focused on the 199 men randomized to TDF/FTC. The total 1-year cost per participant came to 4812 Euros (about $5300), reflecting seven expenses:
-- One counseling session and pre-PrEP workup: 748 Euros
-- About 16 tablets per month: 3129 Euros
-- About 9 ELISA HIV tests: 126 Euros
-- About 4 viral load tests: 16 Euros
-- About 8 consultations: 205 Euros
-- 16 creatinine and liver function tests: 31 Euros
-- Treatment for sexually transmitted infections: 793 Euros
Given the number needed to treat to prevent 1 HIV infection yearly, the investigators calculated that, at current TDF/FTC prices, as-needed PrEP would cost 84,691 Euros (about $93,275) to prevent 1 infection. At current TDF/FTC prices, the incremental cost-effectiveness ratio (ICER) would be 500.88 Euros per 30 TDF/FTC tablets. The ICER would fall to 200.35 Euros per 30 tablets at the French discounted drug price and to 60 Euros per 30 tablets at cost-neutral pricing.
Depending on the antiretroviral regimen used to treat HIV infection, the researchers estimated that the yearly cost of preventing 1 infection with as-needed PrEP would be 3 to 4 times higher than the yearly cost of therapy. But the cost analysis does not reflect other PrEP benefits that the researchers suggested:
-- Prevention of 1.6 to 2.3 secondary HIV infections yearly
-- Treatment of sexually transmitted infections
-- Improved access to health care for HIV-risk populations
-- Improved quality of life
-- Less than lifetime PrEP use for most people versus lifetime antiretroviral therapy
The researchers also noted that as-needed PrEP would be more economically efficient in a population with a higher HIV risk and thus a lower number needed to treat to prevent 1 infection.
References
1. Durand-Zaleski I, Mutuon P, Charreau I, et al. Cost effectiveness of on demand PrEP in men who have sex with men (MSM) in the ANRS IPERGAY study. 21st International AIDS Conference (AIDS 2016). July 18-22, 2016. Durban, South Africa. Abstract THAE0304.
2. Molina JM, Capitant C, Spire B, et al. On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med. 2015;373:2237-2246.
http://www.nejm.org/doi/full/10.1056/NEJMoa1506273
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