title: Cost-effectiveness of Injectable Preexposure Prophylaxis for HIV Prevention in South Africa.
abstract: Long-acting injectable antiretrovirals such as rilpivirine (RPV) could promote adherence to preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention. However, the cost-effectiveness of injectable PrEP is unclear.
  
  
  
  We constructed a dynamic model of the heterosexual HIV epidemic in KwaZulu-Natal, South Africa, and analyzed scenarios of RPV PrEP scale-up for combination HIV prevention in comparison with a reference scenario without PrEP. We estimated new HIV infections, life-years and costs, and incremental cost-effectiveness ratios (ICERs), over 10-year and lifetime horizons, assuming a societal perspective.
  
  
  
  Compared with no PrEP, unprioritized scale-up of RVP PrEP covering 2.5%-15% of adults prevented up to 9% of new infections over 10 years. HIV prevention doubled (17%) when the same coverage was prioritized to 20- to 29-year-old women, costing $10 880-$19 213 per infection prevented. Prioritization of PrEP to 80% of individuals at highest behavioral risk achieved comparable prevention (4%-8%) at <1% overall coverage, costing $298-$1242 per infection prevented. Over lifetime, PrEP scale-up among 20- to 29-year-old women was very cost-effective (<$1600 per life-year gained), dominating unprioritized PrEP, while risk prioritization was cost-saving. PrEP's 10-year impact decreased by almost 50% with increases in ICERs (up to 4.2-fold) in conservative base-case analysis. Sensitivity analysis identified PrEP's costs, efficacy, and reliability of delivery as the principal drivers of uncertainty in PrEP's cost-effectiveness, and PrEP remained cost-effective under the assumption of universal access to second-line antiretroviral therapy.
  
  
  
  Compared with no PrEP, prioritized scale-up of RPV PrEP in KwaZulu-Natal could be very cost-effective or cost-saving, but suboptimal PrEP would erode benefits and increase costs.
authors.affiliation: Departments of Infectious Disease and Quantitative Health Sciences, Cleveland Clinic, Ohio.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Glaubius
authors.affiliation: Pittsburgh Supercomputing Center, Carnegie Mellon University.
authors.forename: Greg
authors.initials: G
authors.lastname: Hood
authors.affiliation: Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pennsylvania.
authors.forename: Kerri J
authors.initials: KJ
authors.lastname: Penrose
authors.affiliation: Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pennsylvania.
authors.forename: Urvi M
authors.initials: UM
authors.lastname: Parikh
authors.affiliation: Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pennsylvania.
authors.forename: John W
authors.initials: JW
authors.lastname: Mellors
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Stanford University, California.
authors.forename: Eran
authors.initials: E
authors.lastname: Bendavid
authors.affiliation: Departments of Infectious Disease and Quantitative Health Sciences, Cleveland Clinic, Ohio Departments of Medicine and Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas.
authors.forename: Ume L
authors.initials: UL
authors.lastname: Abbas
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D003362:Cost-Benefit Analysis; D058872:Epidemics; D005260:Female; D015658:HIV Infections / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D007267:Injections; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D065129:Pre-Exposure Prophylaxis / Q000191:economics* / Q000379:methods; D015203:Reproducibility of Results; D000068696:Rilpivirine / Q000008:administration & dosage*; D013019:South Africa / Q000453:epidemiology; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents; D000068696:Rilpivirine
keywords: HIV infection; HIV prevention intervention; cost-effectiveness; mathematical model; preexposure prophylaxis (PrEP)