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J Acquir Immune Defic Syndr. 2016 Aug 1;72 Suppl 2:S145-53. doi: 10.1097/QAI.0000000000001063.

Cost-Effectiveness of Pre-exposure HIV Prophylaxis During Pregnancy and Breastfeeding in Sub-Saharan Africa.

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*Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, NC; †Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC; ‡Department of Pediatrics and Child Health, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe; §Department of Psychiatry, John Stroger Hospital of Cook County, Chicago, IL; ‖Office of the Global AIDS Coordinator and Health Diplomacy, U.S. Department of State, Washington, DC; ¶Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD; and #Kelly Government Services, Contractor to Prevention Sciences Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.



Antiretroviral pre-exposure prophylaxis (PrEP) for the prevention of HIV acquisition is cost-effective when delivered to those at substantial risk. Despite a high incidence of HIV infection among pregnant and breastfeeding women in sub-Saharan Africa (SSA), a theoretical increased risk of preterm birth on PrEP could outweigh the HIV prevention benefit.


We developed a decision analytic model to evaluate a strategy of daily oral PrEP during pregnancy and breastfeeding in SSA. We approached the analysis from a health care system perspective across a lifetime time horizon. Model inputs were derived from existing literature and local sources. The incremental cost-effectiveness ratio (ICER) of PrEP versus no PrEP was calculated in 2015 U.S. dollars per disability-adjusted life year (DALY) averted. We evaluated the effect of uncertainty in baseline estimates through one-way and probabilistic sensitivity analyses.


PrEP administered to pregnant and breastfeeding women in SSA was cost-effective. In a base case of 10,000 women, the administration of PrEP averted 381 HIV infections but resulted in 779 more preterm births. PrEP was more costly per person ($450 versus $117), but resulted in fewer disability-adjusted life years (DALYs) (3.15 versus 3.49). The incremental cost-effectiveness ratio of $965/DALY averted was below the recommended regional threshold for cost-effectiveness of $6462/DALY. Probabilistic sensitivity analyses demonstrated robustness of the model.


Providing PrEP to pregnant and breastfeeding women in SSA is likely cost-effective, although more data are needed about adherence and safety. For populations at high risk of HIV acquisition, PrEP may be considered as part of a broader combination HIV prevention strategy.

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Conflict of interest statement

BHC received grant funding from the Gilead Foundation to support global health research training. The remaining authors have no conflicts of interest to disclose.

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