title: Implementation and Operational Research: A Cost-Effective, Clinically Actionable Strategy for Targeting HIV Preexposure Prophylaxis to High-Risk Men Who Have Sex With Men.
abstract: Preexposure prophylaxis (PrEP) is effective at preventing HIV infection among men who have sex with men (MSM), but there is uncertainty about how to identify high-risk MSM who should receive PrEP.
  
  
  
  We used a mathematical model to assess the cost-effectiveness of using the HIV Incidence Risk Index for MSM (HIRI-MSM) questionnaire to target PrEP to high-risk MSM. We simulated strategies of no PrEP, PrEP available to all MSM, and eligibility thresholds set to HIRI-MSM scores between 5 and 45, in increments of 5 (where a higher score predicts greater HIV risk). Based on the iPrEx, IPERGAY, and PROUD trials, we evaluated PrEP efficacies from 44% to 86% and annual costs from $5900 to 8700. We designate strategies with incremental cost-effectiveness ratio (ICER) ≤$100,000/quality-adjusted life-year (QALY) as "cost-effective."
  
  
  
  Over 20 years, making PrEP available to all MSM is projected to prevent 33.5% of new HIV infections, with an ICER of $1,474,000/QALY. Increasing the HIRI-MSM score threshold reduces the prevented infections, but improves cost-effectiveness. A threshold score of 25 is projected to be optimal (most QALYs gained while still being cost-effective) over a wide range of realistic PrEP efficacies and costs. At low cost and high efficacy (IPERGAY), thresholds of 15 or 20 are optimal across a range of other input assumptions; at high cost and low efficacy (iPrEx), 25 or 30 are generally optimal.
  
  
  
  The HIRI-MSM provides a clinically actionable means of guiding PrEP use. Using a score of 25 to determine PrEP eligibility could facilitate cost-effective use of PrEP among high-risk MSM who will benefit from it most.
authors.affiliation: *University of Michigan Medical School, Ann Arbor, MI;†Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System and Veterans Affairs Ann Arbor Health System, Ann Arbor, MI;‡Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI; and§Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI.
authors.forename: Eric L
authors.initials: EL
authors.lastname: Ross
authors.forename: Sandro K
authors.initials: SK
authors.lastname: Cinti
authors.forename: David W
authors.initials: DW
authors.lastname: Hutton
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics / Q000458:organization & administration*; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control*; D018451:Homosexuality, Male; D006801:Humans; D015994:Incidence; D008297:Male; D008403:Mass Screening / Q000191:economics; D009874:Operations Research; D065129:Pre-Exposure Prophylaxis / Q000191:economics; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D014481:United States / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents