Potential Impact and Cost-Effectiveness of Condomless-Sex-Concentrated PrEP in KwaZulu-Natal Accounting for Drug Resistance

Andrew N Phillips; Valentina Cambiano; Leigh Johnson; Fumiyo Nakagawa; Rick Homan; Gesine Meyer-Rath; Thomas Rehle; Frank Tanser; Sizulu Moyo; Maryam Shahmanesh; Delivette Castor; Elizabeth Russell; Lise Jamieson; Loveleen Bansi-Matharu; Amir Shroufi; Ruanne V Barnabas; Urvi M Parikh; John W Mellors; Paul Revill

doi:10.1093/infdis/jiz667

Potential Impact and Cost-Effectiveness of Condomless-Sex-Concentrated PrEP in KwaZulu-Natal Accounting for Drug Resistance

J Infect Dis. 2021 Apr 23;223(8):1345-1355. doi: 10.1093/infdis/jiz667.

Authors

Andrew N Phillips¹, Valentina Cambiano¹, Leigh Johnson², Fumiyo Nakagawa¹, Rick Homan³, Gesine Meyer-Rath^{4

5

6}, Thomas Rehle², Frank Tanser^{7

8

9

10}, Sizulu Moyo¹¹, Maryam Shahmanesh^{1

8}, Delivette Castor¹², Elizabeth Russell¹², Lise Jamieson^{4

5}, Loveleen Bansi-Matharu¹, Amir Shroufi¹³, Ruanne V Barnabas¹⁴, Urvi M Parikh¹⁵, John W Mellors¹⁵, Paul Revill¹⁶

Affiliations

¹ Institute for Global Health, University College London, London, UK.
² Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.
³ FHI 360, Durham, North Carolina, USA.
⁴ Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa.
⁵ Health Economics and Epidemiology Research Office, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa.
⁶ Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA.
⁷ Lincoln Institute for Health, University of Lincoln, Lincoln, UK.
⁸ Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa.
⁹ School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
¹⁰ Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa.
¹¹ Human Sciences Research Council, Pretoria, South Africa.
¹² United States Agency for International Development, Washington, District of Columbia, USA.
¹³ Medécins Sans Frontières, Cape Town, South Africa.
¹⁴ University of Washington, Seattle, Washington, USA.
¹⁵ University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
¹⁶ University of York, York, UK.

Abstract

Introduction: Oral preexposure prophylaxis (PrEP) in the form of tenofovir-disoproxil-fumarate/emtricitabine is being implemented in selected sites in South Africa. Addressing outstanding questions on PrEP cost-effectiveness can inform further implementation.

Methods: We calibrated an individual-based model to KwaZulu-Natal to predict the impact and cost-effectiveness of PrEP, with use concentrated in periods of condomless sex, accounting for effects on drug resistance. We consider (1) PrEP availability for adolescent girls and young women aged 15-24 years and female sex workers, and (2) availability for everyone aged 15-64 years. Our primary analysis represents a level of PrEP use hypothesized to be attainable by future PrEP programs.

Results: In the context of PrEP use in adults aged 15-64 years, there was a predicted 33% reduction in incidence and 36% reduction in women aged 15-24 years. PrEP was cost-effective, including in a range of sensitivity analyses, although with substantially reduced (cost) effectiveness under a policy of ART initiation with efavirenz- rather than dolutegravir-based regimens due to PrEP undermining ART effectiveness by increasing HIV drug resistance.

Conclusions: PrEP use concentrated during time periods of condomless sex has the potential to substantively impact HIV incidence and be cost-effective.

Keywords: HIV; PrEP; South Africa; cost; cost-effectiveness analysis; drug resistance; individual-based; model.

Publication types

Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

Adolescent
Adult
Anti-HIV Agents* / economics
Anti-HIV Agents* / therapeutic use
Cost-Benefit Analysis
Drug Resistance
Emtricitabine / therapeutic use
Female
HIV Infections* / drug therapy
HIV Infections* / prevention & control
Humans
Male
Middle Aged
Models, Theoretical
Pre-Exposure Prophylaxis* / economics
Sex Workers*
South Africa / epidemiology
Unsafe Sex*
Young Adult

Substances

Anti-HIV Agents
Emtricitabine

Abstract

Publication types

MeSH terms

Substances

Grants and funding