Cost-effectiveness of PrEP in HIV/AIDS control in Zambia: a stochastic league approach.
BACKGROUND
Earlier antiretroviral therapy initiation and pre-exposure prophylaxis (PrEP) prevent HIV, although at a substantial cost. We use mathematical modeling to compare the cost-effectiveness and economic affordability of antiretroviral-based prevention strategies in rural Macha, Zambia.


METHODS
We compare the epidemiological impact and cost-effectiveness over 40 years of a baseline scenario (treatment initiation at CD4 <350 cells/μL) with treatment initiation at CD4 <500 cells per microliter, and PrEP (prioritized to the most sexually active, or nonprioritized). A strategy is cost effective when the incremental cost-effectiveness ratio (ICER) is <$3480 (<3 times Zambian per capita GDP). Stochastic league tables then predict the optimal intervention per budget level.


RESULTS
All scenarios will reduce the prevalence from 6.2% (interquartile range, 5.8%-6.6%) in 2014 to about 1% after 40 years. Compared with the baseline, 16% of infections will be averted with prioritized PrEP plus treatment at CD4 <350, 34% with treatment at CD4 <500, and 59% with nonprioritized PrEP plus treatment at CD4 <500. Only treating at CD4 <500 is cost effective: ICER of $62 ($46-$75). Nonprioritized PrEP plus treating at CD4 <500 is borderline cost effective: ICER of $5861 ($3959-$8483). Initiating treatment at CD4 <500 requires a budget increase from $20 million to $25 million over 40 years, with a 96.7% probability of being the optimal intervention. PrEP should only be considered when the budget exceeds $180 million.


CONCLUSIONS
Treatment initiation at CD4 <500 is a cost-effective HIV prevention approach that will require a modest increase in budget. Although adding PrEP will avert more infections, it is not economically feasible, as it requires a 10-fold increase in budget.
*Department of Viroscience, Erasmus Medical Centre, Rotterdam, the Netherlands; †Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands; ‡Macha Mission Hospital and Macha Research Trust, Macha, Zambia; and §Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Centre, Rotterdam, the Netherlands.
Brooke E
BE
Nichols
Rob
R
Baltussen
Janneke H
JH
van Dijk
Phil E
PE
Thuma
Jan L
JL
Nouwen
Charles A B
CA
Boucher
David A M C
DA
van de Vijver
D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy / Q000191:economics* / Q000453:epidemiology* / Q000517:prevention & control*; D019380:Anti-HIV Agents / Q000191:economics / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D003362:Cost-Benefit Analysis; D015658:HIV Infections / Q000188:drug therapy / Q000191:economics* / Q000453:epidemiology* / Q000517:prevention & control*; D006801:Humans; D018803:Models, Economic; D015995:Prevalence; D015024:Zambia
D019380:Anti-HIV Agents