Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United States.
BACKGROUND
The total population health benefits and costs of HIV preexposure prophylaxis (PrEP) for people who inject drugs (PWID) in the United States are unclear.


OBJECTIVE
To evaluate the cost-effectiveness and optimal delivery conditions of PrEP for PWID.


METHODS
Empirically calibrated dynamic compartmental model.


METHODS
Published literature and expert opinion.


METHODS
Adult U.S. PWID.


METHODS
20 years and lifetime.


METHODS
PrEP alone, PrEP with frequent screening (PrEP+screen), and PrEP+screen with enhanced provision of antiretroviral therapy (ART) for individuals who become infected (PrEP+screen+ART). All scenarios are considered at 25% coverage.


METHODS
Infections averted, deaths averted, change in HIV prevalence, discounted costs (in 2015 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.


RESULTS
PrEP+screen+ART dominates other strategies, averting 26 700 infections and reducing HIV prevalence among PWID by 14% compared with the status quo. Achieving these benefits costs $253 000 per QALY gained. At current drug prices, total expenditures for PrEP+screen+ART could be as high as $44 billion over 20 years.


RESULTS
Cost-effectiveness of the intervention is linear in the annual cost of PrEP and is dependent on PrEP drug adherence, individual transmission risks, and community HIV prevalence.


CONCLUSIONS
Data on risk stratification and achievable PrEP efficacy levels for U.S. PWID are limited.


CONCLUSIONS
PrEP with frequent screening and prompt treatment for those who become infected can reduce HIV burden among PWID and provide health benefits for the entire U.S. population, but, at current drug prices, it remains an expensive intervention both in absolute terms and in cost per QALY gained.


BACKGROUND
National Institute on Drug Abuse.
Cora L
CL
Bernard
Margaret L
ML
Brandeau
Keith
K
Humphreys
Eran
E
Bendavid
Mark
M
Holodniy
Christopher
C
Weyant
Douglas K
DK
Owens
Jeremy D
JD
Goldhaber-Fiebert