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PrEP for HIV cost-effective if targeted properly

Wednesday April 18, 2012
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A once-a-day pill to help prevent HIV infection could significantly reduce the spread of AIDS, but only makes economic sense if used in select, high-risk groups, according to a study.

Researchers affiliated with Stanford University looked at the cost-effectiveness of the combination drug tenofovir-emtricitabine, which was found in a 2010 trial to reduce an individualís risk of HIV infection by 44% when taken daily. Patients who were especially faithful about taking the drug reduced their risk by 73%.

The results generated so much interest that the Stanford researchers decided to see whether pre-exposure prophylaxis would be cost-effective. They created an economic model focused on men who have sex with other men (MSM), a group that accounts for more than half of the estimated 56,000 new infections each year in the United States, according to the Centers for Disease Control and Prevention.

"Promoting PrEP to all men who have sex with men could be prohibitively expensive," Jessie Juusola, a PhD candidate in management science and engineering in the School of Engineering, and first author of the study, said in a news release. "Adopting it for men who have sex with men at high risk of acquiring HIV, however, is an investment with good value that does not break the bank."

Using the pill in the general MSM population would cost $495 billion over 20 years, compared to $85 billion when targeted to those at particularly high risk, the researchers found.

Senior author Eran Bendavid, MD, assistant professor of medicine in the School of Medicine, said the results are a departure from a previous study, which found PrEP was not cost-effective when compared with other commonly accepted prevention programs. The researchers said the new study differs in a few important respects, including by taking into consideration the decline in transmission rates over time as more individuals take the pill. The Stanford team also assumed individuals would stop taking PrEP after 20 years, not stay on the drug for life, as the previous study had assumed.

In developing their model, the researchers took into account the cost of the drug — about $26 a day, or almost $10,000 a year — as well as the expenses for physician visits, periodic monitoring of kidney function affected by the drug and regular testing for HIV and sexually transmitted diseases.

Without PrEP, the researchers calculated there would be more than 490,000 new infections among the MSM population in the United States in the next 20 years. If only 20% of these men took the pill daily, there would be nearly 63,000 fewer infections.

However, use of the drug by 20% of the MSM population would cost $98 billion over 20 years. If every man in that group took PrEP for 20 years, the cost would be $495 billion.

Given these figures, the researchers looked at the option of giving PrEP only to men who are at high risk, defined as those who have five or more sexual partners in a year. If only 20% of these high-risk individuals took the drug, 41,000 new infections would be prevented over 20 years at a cost of about $16.6 billion.

At less than $50,000 per quality-adjusted life year gained (a measure of how long people live and their quality of life), that strategy represents relatively good value, according to Juusola.

"However, even though it provides good value, it is still very expensive," she said. "In the current healthcare climate, PrEPís costs may become prohibitive, especially given the other competing priorities for HIV resources, such as providing treatment for infected individuals."

She said the costs could be significantly reduced if the pill is found to be effective when used intermittently, rather than on a daily basis. Trials are examining the effectiveness of the drug when used less often.

The study appears in the April 17 issue of the Annals of Internal Medicine. To view the data and access the study via subscription or purchase, visit http://bit.ly/Je9bBH.

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