title: Cost-effectiveness of pre-exposure prophylaxis targeted to high-risk serodiscordant couples as a bridge to sustained ART use in Kampala, Uganda.
abstract: BACKGROUND
  Despite scale-up of antiretroviral therapy (ART) for treating HIV-positive persons, HIV incidence remains elevated among those at high risk such as persons in serodiscordant partnerships. Antiretrovirals taken by HIV-negative persons as pre-exposure prophylaxis (PrEP) has the potential to avert infections in individuals in serodiscordant partnerships. Evaluating the cost-effectiveness of implementing time-limited PrEP as a short-term bridge during the first six months of ART for the HIV-positive partner to prevent HIV transmission compared to increasing ART coverage is crucial to informing policy-makers considering PrEP implementation.
  
  
  METHODS
  To estimate the real world delivery costs of PrEP, we conducted micro-costing and time and motion analyses in an open-label prospective study of PrEP and ART delivery targeted to high-risk serodiscordant couples in Uganda (the Partners Demonstration Project). The cost (in USD, in 2012) of PrEP and ART for serodiscordant couples was assessed, with and without research components, in the study setting. Using Ministry of Health costs, the cost of PrEP and ART provision within a government programme was estimated, as was the cost of providing PrEP in addition to ART. We parameterized an HIV transmission model to estimate the health and economic impacts of 1) PrEP and ART targeted to high-risk serodiscordant couples in the context of current ART use and 2) increasing ART coverage to 55% of HIV-positive persons with CD4 ≤500 cells/µL without PrEP. The incremental cost-effectiveness ratios (ICERs) per HIV infection and disability-adjusted life year (DALY) averted were calculated over 10 years.
  
  
  RESULTS
  The annual cost of PrEP and ART delivery for serodiscordant couples was $1058 per couple in the study setting and $453 in the government setting. The portion of the programme cost due to PrEP was $408 and $92 per couple per year in the study and government settings, respectively. Over 10 years, a programme of PrEP and ART for high-risk serodiscordant couples was projected to avert 43% of HIV infections compared to current practice with an ICER of $1340 per infection averted. This was comparable to ART expansion alone, which would avert 37% of infections with an ICER of $1452.
  
  
  CONCLUSIONS
  Using Uganda's gross domestic product per capita of $1681 as a threshold, PrEP and ART for high-risk persons have the potential for synergistic action and are cost-effective in preventing HIV infections in high prevalence settings. The annual cost of PrEP in this programme is less than $100 per serodiscordant couple if implemented in public clinics.
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA.
authors.forename: Roger
authors.initials: R
authors.lastname: Ying
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA.
authors.forename: Monisha
authors.initials: M
authors.lastname: Sharma
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA.
authors.forename: Renee
authors.initials: R
authors.lastname: Heffron
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA.|Department of Epidemiology, University of Washington, Seattle, WA, USA.|Department of Medicine, University of Washington, Seattle, WA, USA.
authors.forename: Connie L
authors.initials: CL
authors.lastname: Celum
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA.|Department of Epidemiology, University of Washington, Seattle, WA, USA.|Department of Medicine, University of Washington, Seattle, WA, USA.
authors.forename: Jared M
authors.initials: JM
authors.lastname: Baeten
authors.affiliation: Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: Elly
authors.initials: E
authors.lastname: Katabira
authors.affiliation: Infectious Disease Institute, College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: Nulu
authors.initials: N
authors.lastname: Bulya
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA.|Department of Epidemiology, University of Washington, Seattle, WA, USA.|Department of Medicine, University of Washington, Seattle, WA, USA.|Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; rbarnaba@uw.edu.
authors.forename: Ruanne V
authors.initials: RV
authors.lastname: Barnabas
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D017048:Health Care Costs; D006801:Humans; D008297:Male; D065129:Pre-Exposure Prophylaxis / Q000191:economics*; D012747:Sexual Partners; D014454:Uganda
chemical_list: D019380:Anti-HIV Agents
keywords: ART; PrEP; cost-effectiveness analysis; mathematical modelling; serodiscordant couples