title: Evaluating the impact of prioritization of  antiretroviral pre-exposure prophylaxis  in New York.
abstract: To compare the value and effectiveness of different prioritization strategies of pre-exposure prophylaxis (PrEP) in New York City (NYC).
  
  
  
  Mathematical modelling utilized as clinical trial is not feasible.
  
  
  
  Using a model accounting for both sexual and parenteral transmission of HIV, we compare different PrEP prioritization strategies (PPS) with two scenarios – no PrEP and PrEP for all susceptible at-risk individuals. The PPS included PrEP for all MSM,only high-risk MSM, high-risk heterosexuals, and IDUs, and all combinations of these four strategies. Outcomes included HIV infections averted, and incremental cost effectiveness(per-infection averted) ratios. Initial assumptions regarding PrEP included a 44% reduction in HIV transmission, 50% uptake in the prioritized population and an annual cost per person of $9762. Sensitivity analyses on key parameters were conducted.
  
  
  
  Prioritization to all MSM results in a 19% reduction in new HIV infections. Compared with PrEP for all persons at-risk, this PPS retains 79% of the preventive effect at 15% of the total cost. PrEP prioritized to only high-risk MSM results in a reduction in new HIV infections of 15%. This PPS retains 60% of the preventive effect at 6% of the total cost. There are diminishing returns when PrEP utilization is expanded beyond this group.
  
  
  
  PrEP implementation is relatively cost-inefficient under our initial assumptions. Our results suggest that PrEP should first be promoted among MSM who are at particularly high risk of HIV acquisition. Further expansion beyond this group may be cost-effective, but is unlikely to be cost-saving.
authors.affiliation: Division of Comparative Effectiveness and Decision Science, Department of Population Health, New York University School of Medicine, NY, USA.   Jason.Kessler@nyumc.org
authors.forename: Jason
authors.initials: J
authors.lastname: Kessler
authors.forename: Julie E
authors.initials: JE
authors.lastname: Myers
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Nucifora
authors.forename: Nana
authors.initials: N
authors.lastname: Mensah
authors.forename: Christopher
authors.initials: C
authors.lastname: Toohey
authors.forename: Amin
authors.initials: A
authors.lastname: Khademi
authors.forename: Blayne
authors.initials: B
authors.lastname: Cutler
authors.forename: Scott
authors.initials: S
authors.lastname: Braithwaite
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D018890:Chemoprevention / Q000191:economics / Q000379:methods; D018562:Disease Transmission, Infectious / Q000517:prevention & control*; D005260:Female; D015658:HIV Infections / Q000453:epidemiology* / Q000517:prevention & control* / Q000635:transmission; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D009519:New York City / Q000453:epidemiology; D065129:Pre-Exposure Prophylaxis / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data*; D016896:Treatment Outcome
chemical_list: D044966:Anti-Retroviral Agents