October 07, 2016
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PrEP deemed cost-effective in the Netherlands

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Pre-exposure prophylaxis, or PrEP, is a cost-effective approach to reducing HIV among men who have sex with men in the Netherlands, according to a mathematical modeling study published in the Lancet Infectious Diseases.

Both daily and on-demand PrEP with Truvada (emtricitabine/tenofovir disoproxil fumarate, Gilead Sciences) are known to be effective in preventing HIV infections among MSM, but use of PrEP is limited because it is not reimbursed in most European countries.

“To determine the full benefit of PrEP, the number of secondary HIV cases prevented, through the snowball effect, should be taken into account,” Brooke E. Nichols, PhD, a researcher in the viroscience department at Erasmus Medical Center, Rotterdam, Netherlands, and colleagues wrote.

In the study, the researchers constructed a mathematical model of the Dutch HIV epidemic among MSM from 2008 to 2014, based on data described in a national HIV database, to predict the benefits and cost-effectiveness of PrEP. In the model, PrEP was targeted to 10% of the most highly sexually active Dutch MSM across a future 40-year period. The researchers calculated incremental cost-effectiveness ratios that compared incremental costs and quality-adjusted life-years (QALY) of PrEP use (both daily and on-demand) with no PrEP use. Cost-effectiveness ratios below 20,000 euros were considered cost-effective, as is standard in the Netherlands for disease prevention strategies.

In the context of a stable epidemic, the model predicted that, if PrEP was 40% effective, 1,400 (interquartile range [IQR], 1,200-1,600) new infections could be prevented in 12 years, including 2 years of scale-up and 10 years of full implementation. If PrEP was 100% effective, 2,500 (IQR, 2,100-3,100) new infections could be prevented compared with no PrEP.

If the current price of tenofovir and emtricitabine remained constant and PrEP is at least 70% effective, the researchers predicted that PrEP would cost less than 20,000 euros per QALY gained, regardless of changes in the HIV epidemic.

At current pricing and 80% effectiveness, within the context of a stable HIV epidemic, PrEP can cost as much as 11,000 (IQR, 9,400-14,100) euros per QALY gained with daily use, or as little as 2,000 (IQR, 1,300-3,000) euros per QALY when used on demand.

At 80% effectiveness, daily PrEP could be considered cost-saving if its price is reduced by 70%, and on-demand PrEP could be considered cost-saving if its price is reduced by 30% to 40%. Given that patents for tenofovir and emtricitabine are soon expiring, the researchers noted that price reductions can be expected.

“A reduction in the price of a PrEP regimen would help to ensure and maximize the long-term sustainability of PrEP,” the researchers concluded. “PrEP for HIV prevention should be considered for implementation throughout the Netherlands and in countries with similar epidemics.”

In a related editorial, Louis Niessen, MD, PhD, and Shabbar Jaffar, PhD, both professors at the Liverpool School of Tropical Medicine, said the study’s findings, while plausible, may not be generalizable and that more “specific empirical evaluation and implementation research” is required to determine the value of PrEP on a global scale.

“We now know that large-scale implementation of effective prevention strategies will be necessary to measure population impact and to reduce the already huge burden on the health systems and households without advanced health services and health financing mechanisms,” they concluded. – by Sarah Kennedy

Disclosures: Nichols reports receiving grants from Gilead Sciences, Janssen, Merck and ViiV Healthcare outside of the study. Jaffar and Niessen report no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.