Modelling the impact and cost-effectiveness of combination prevention amongst HIV serodiscordant couples in Nigeria.
OBJECTIVE
To estimate the impact and cost-effectiveness of treatment as prevention (TasP), pre-exposure prophylaxis (PrEP) and condom promotion for serodiscordant couples in Nigeria.


METHODS
Mathematical and cost modelling.


METHODS
A deterministic model of HIV-1 transmission within a cohort of serodiscordant couples and to/from external partners was parameterized using data from Nigeria and other African settings. The impact and cost-effectiveness were estimated for condom promotion, PrEP and/or TasP, compared with a baseline where antiretroviral therapy (ART) was offered according to 2010 national guidelines (CD4 <350 cells/μl) to all HIV-positive partners. The impact was additionally compared with a baseline of current ART coverage (35% of those with CD4 <350 cells/μl). Full costs (in US $2012) of programme introduction and implementation were estimated from a provider perspective.


RESULTS
Substantial benefits came from scaling up ART to all HIV-positive partners according to 2010 national guidelines, with additional smaller benefits of providing TasP, PrEP or condom promotion. Compared with a baseline of offering ART to all HIV-positive partners at the 2010 national guidelines, condom promotion was the most cost-effective strategy [US $1206/disability-adjusted-life-year (DALY)], the next most cost-effective intervention was to additionally give TasP to HIV-positive partners (incremental cost-effectiveness ratio US $1607/DALY), followed by additionally giving PrEP to HIV-negative partners until their HIV-positive partners initiate ART (US $7870/DALY). When impact was measured in terms of infections averted, PrEP with condom promotion prevented double the number of infections as condom promotion alone.


CONCLUSIONS
The first priority intervention for serodiscordant couples in Nigeria should be scaled up ART access for HIV-positive partners. Subsequent incremental benefits are greatest with condom promotion and TasP, followed by PrEP.
aLondon School of Hygiene and Tropical Medicine, London, UK bFamily Health International, Abuja cObafemi Awolowo University and New HIV Vaccine and Microbicide Advocacy Society, Lagos dUniversity of Jos, Jos eNational Agency for the Control of AIDS, Abuja, Nigeria fUniversity of Bristol, Bristol, UK.
Kate M
KM
Mitchell
Aurélia
A
Lépine
Fern
F
Terris-Prestholt
Kwasi
K
Torpey
Hadiza
H
Khamofu
Morenike O
MO
Folayan
Jonah
J
Musa
James
J
Anenih
Atiene S
AS
Sagay
Emmanuel
E
Alhassan
John
J
Idoko
Peter
P
Vickerman
D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000008:administration & dosage / Q000191:economics; D018890:Chemoprevention / Q000191:economics / Q000379:methods; D015331:Cohort Studies; D017280:Condoms / Q000191:economics / Q000706:statistics & numerical data; D003362:Cost-Benefit Analysis; D018562:Disease Transmission, Infectious / Q000517:prevention & control*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000517:prevention & control* / Q000635:transmission*; D018023:HIV Seronegativity; D006679:HIV Seropositivity; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D009549:Nigeria; D065129:Pre-Exposure Prophylaxis / Q000191:economics* / Q000379:methods*; D012747:Sexual Partners; D055815:Young Adult
D044966:Anti-Retroviral Agents