Model finds universal HIV PrEP not cost-effective for injection drug users
Money instead spent on issues related to injection drug use, such as naloxone therapy and detoxification programs, would not only prevent HIV infections but also save lives, an editorial noted.
HIV preexposure prophylaxis (PrEP) is currently too expensive to provide to all people in the U.S. who inject drugs, an economic model found.
To determine the cost and health benefits of implementing a national PrEP program for injection drug users, researchers developed an empirically calibrated dynamic compartmental model of the U.S. HIV population. The model considered programs of PrEP alone, PrEP with frequent screening, and PrEP with frequent screening and prompt treatment with antiretroviral therapy (ART) for those who become infected. All scenarios assumed 25% coverage.
The model considered 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 were published online April 25 by Annals of Internal Medicine.
Over 20 years, PrEP plus screening plus ART was more effective than the other strategies, averting 26,700 infections and reducing HIV prevalence among injection drug users by 14% compared to the status quo. Achieving these benefits costs $253,000/QALY gained. Researchers noted that, at current drug prices, total expenditures for this strategy could be as high as $44 billion over 20 years, which the authors noted equaled 10% of the current annual federal budget for domestic HIV/AIDS programs. The intervention would prevent about 21,500 new infections over 20 years, making it cost-prohibitive in both absolute terms and in cost per QALY gained, they wrote.
The author of an accompanying editorial said that even at lower drug prices, HIV PrEP for injection drug users may not be an efficient use of HIV prevention resources. Other problems related to injection drug use, such as overdoses, are far greater than the no-longer-deadly threat of HIV itself, according to the editorialist.
“What good is preventing HIV if we do not first save that life at HIV risk?” the editorial asked. “Investments in access to naloxone therapy, medical insurance, and detoxification programs, opioid agonist therapy, and needle exchange will serve not only to prevent HIV infections (in some cases, at incident-reduction efficacies of 56% to 64% higher than that of PrEP), they may simultaneously prove to be immediately life-saving.”