Background:
The total population health benefits and costs of HIV preexposure prophylaxis (PrEP) for people who inject drugs (PWID) in the United States are unclear.
Objective:
To evaluate the cost-effectiveness and optimal delivery conditions of PrEP for PWID.
Design:
Empirically calibrated dynamic compartmental model.
Data Sources:
Published literature and expert opinion.
Target Population:
Adult U.S. PWID.
Time Horizon:
20 years and lifetime.
Intervention:
PrEP alone, PrEP with frequent screening (PrEP+screen), and PrEP+screen with enhanced provision of antiretroviral therapy (ART) for individuals who become infected (PrEP+screen+ART). All scenarios are considered at 25% coverage.
Outcome Measures:
Infections averted, deaths averted, change in HIV prevalence, discounted costs (in 2015 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.
Results of Base-Case Analysis:
PrEP+screen+ART dominates other strategies, averting 26 700 infections and reducing HIV prevalence among PWID by 14% compared with the status quo. Achieving these benefits costs $253 000 per QALY gained. At current drug prices, total expenditures for PrEP+screen+ART could be as high as $44 billion over 20 years.
Results of Sensitivity Analysis:
Cost-effectiveness of the intervention is linear in the annual cost of PrEP and is dependent on PrEP drug adherence, individual transmission risks, and community HIV prevalence.
Limitation:
Data on risk stratification and achievable PrEP efficacy levels for U.S. PWID are limited.
Conclusion:
PrEP with frequent screening and prompt treatment for those who become infected can reduce HIV burden among PWID and provide health benefits for the entire U.S. population, but, at current drug prices, it remains an expensive intervention both in absolute terms and in cost per QALY gained.
Primary Funding Source:
National Institute on Drug Abuse.
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Author, Article, and Disclosure Information
From Stanford University, Stanford, and Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
Disclaimer: The views expressed are those of the authors and do not necessarily reflect the opinion of the Department of Veterans Affairs or U.S. government.
Grant Support: By grant R01-DA15612 from the National Institute on Drug Abuse. Ms. Bernard was supported by a PACCAR Inc. Stanford Graduate Fellowship and a National Science Foundation Graduate Fellowship (DGE-114747). Christopher Weyant was supported by a Stanford Department of Management Science and Engineering Graduate Fellowship and a National Science Foundation Graduate Fellowship (DGE-114747). Drs. Owens, Humphreys, and Holodniy were supported by the Department of Veterans Affairs. Dr. Goldhaber-Fiebert was supported by a Career Development Award (K01AG037593-01A1) from the National Institute on Aging.
Disclosures: Ms. Bernard reports grants from National Science Foundation and Stanford University PACCAR Inc. Graduate Fellowship during the conduct of the study. Dr. Brandeau reports grants from National Institute on Drug Abuse during the conduct of the study. Dr. Weyant reports grants from National Science Foundation during the conduct of the study. Dr. Owens reports grants from NIH during the conduct of the study. Dr. Goldhaber-Fiebert reports grants from NIH/NIA (K01 AG037593) during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictsOfInterestForms.do?msNum=M15-2634.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Not applicable. Statistical code: Additional detail can be made available where technical appendix is insufficient by contacting Cora Bernard (e-mail, [email protected]
Corresponding Author: Cora L. Bernard, MS, Department of Management Science and Engineering, Huang Engineering Center, 475 Via Ortega, Stanford University, Stanford, CA 94305-4026; e-mail, [email protected]
Current Author Addresses: Ms. Bernard: Department of Management Science and Engineering, Huang Engineering Center, 475 Via Ortega, Stanford University, Stanford, CA 94305-4026.
Dr. Brandeau: Department of Management Science and Engineering, Huang Engineering Center, 475 Via Ortega, Stanford University, Stanford, CA 94305-4026.
Dr. Humphreys: Stanford School of Medicine, Department of Psychiatry, 401 N. Quarry Road, Room C-305, Stanford, CA 94305-5717.
Dr. Bendavid: Center for Primary Care and Outcomes Research/Center for Health Policy, Stanford University, 117 Encina Commons, Room 204, Stanford, CA 94305-6019.
Dr. Holodniy: AIDS Research Center, VA Palo Alto Health Care System, 3801 Miranda Ave. (132), Palo Alto, California 94304-5107.
Mr. Weyant: Department of Management Science and Engineering, Huang Engineering Center, 475 Via Ortega, Stanford University, Stanford, CA 94305-4026.
Dr. Owens: Center for Primary Care and Outcomes Research/Center for Health Policy , Stanford University, 117 Encina Commons, Stanford, CA 94305-6019.
Dr. Goldhaber-Fiebert: Center for Primary Care and Outcomes Research/Center for Health Policy, Stanford University, 117 Encina Commons, Room 217, Stanford, CA 94305-6019.
Author Contributions: Conception and design: E. Bendavid, C.L. Bernard, M.L. Brandeau, J.D. Goldhaber-Fiebert, K. Humphreys, D.K. Owens, C. Weyant.
Analysis and interpretation of the data: C.L. Bernard, M.L. Brandeau, J.D. Goldhaber-Fiebert, M. Holodniy, K. Humphreys, D.K. Owens, C. Weyant.
Drafting of the article: C.L. Bernard, J.D. Goldhaber-Fiebert, D.K. Owens.
Critical revision for important intellectual content: E. Bendavid, C.L. Bernard, M.L. Brandeau, J.D. Goldhaber-Fiebert, M. Holodniy, K. Humphreys, D.K. Owens.
Final approval of the article: E. Bendavid, C.L. Bernard, M.L. Brandeau, J.D. Goldhaber-Fiebert, M. Holodniy, K. Humphreys, D.K. Owens, C. Weyant.
Statistical expertise: C.L. Bernard, J.D. Goldhaber-Fiebert, D.K. Owens.
Obtaining of funding: M.L. Brandeau, J.D. Goldhaber-Fiebert, D.K. Owens.
Administrative, technical, or logistic support: D.K. Owens.
Collection and assembly of data: E. Bendavid, C.L. Bernard, D.K. Owens, C. Weyant.
This article was published at www.annals.org on 26 April 2016.
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