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J Int AIDS Soc. 2018 Mar;21(3):e25096. doi: 10.1002/jia2.25096.

The cost-effectiveness of HIV pre-exposure prophylaxis in men who have sex with men and transgender women at high risk of HIV infection in Brazil.

Author information

1
The Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
2
Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.
3
Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
4
Harvard University Center for AIDS Research, Harvard Medical School, Boston, MA, USA.
5
Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
6
Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA.
7
Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA.
8
Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA.
9
Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
10
Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA.
11
Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA.
12
Yale School of Public Health, New Haven, CT, USA.

Abstract

INTRODUCTION:

Men who have sex with men (MSM) and transgender women (TGW) in Brazil experience high rates of HIV infection. We examined the clinical and economic outcomes of implementing a pre-exposure prophylaxis (PrEP) programme in these populations.

METHODS:

We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-International model of HIV prevention and treatment to evaluate two strategies: the current standard of care (SOC) in Brazil, including universal ART access (No PrEP strategy); and the current SOC plus daily tenofovir/emtracitabine PrEP (PrEP strategy) until age 50. Mean age (31 years, SD 8.4 years), age-stratified annual HIV incidence (age ≤ 40 years: 4.3/100 PY; age > 40 years: 1.0/100 PY), PrEP effectiveness (43% HIV incidence reduction) and PrEP drug costs ($23/month) were from Brazil-based sources. The analysis focused on direct medical costs of HIV care. We measured the comparative value of PrEP in 2015 United States dollars (USD) per year of life saved (YLS). Willingness-to-pay threshold was based on Brazil's annual per capita gross domestic product (GDP; 2015: $8540 USD).

RESULTS:

Lifetime HIV infection risk among high-risk MSM and TGW was 50.5% with No PrEP and decreased to 40.1% with PrEP. PrEP increased per-person undiscounted (discounted) life expectancy from 36.8 (20.7) years to 41.0 (22.4) years and lifetime discounted HIV-related medical costs from $4100 to $8420, which led to an incremental cost-effectiveness ratio (ICER) of $2530/YLS. PrEP remained cost-effective (<1x GDP) under plausible variation in key parameters, including PrEP effectiveness and cost, initial cohort age and HIV testing frequency on/off PrEP.

CONCLUSION:

Daily tenofovir/emtracitabine PrEP among MSM and TGW at high risk of HIV infection in Brazil would increase life expectancy and be highly cost-effective.

KEYWORDS:

Brazil; HIV; cost-effectiveness; men who have sex with men; pre-exposure prophylaxis

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