title: Cost-Effectiveness of Pre-exposure HIV Prophylaxis During Pregnancy and Breastfeeding in Sub-Saharan Africa.
abstract: Antiretroviral pre-exposure prophylaxis (PrEP) for the prevention of HIV acquisition is cost-effective when delivered to those at substantial risk. Despite a high incidence of HIV infection among pregnant and breastfeeding women in sub-Saharan Africa (SSA), a theoretical increased risk of preterm birth on PrEP could outweigh the HIV prevention benefit.
  
  
  
  We developed a decision analytic model to evaluate a strategy of daily oral PrEP during pregnancy and breastfeeding in SSA. We approached the analysis from a health care system perspective across a lifetime time horizon. Model inputs were derived from existing literature and local sources. The incremental cost-effectiveness ratio (ICER) of PrEP versus no PrEP was calculated in 2015 U.S. dollars per disability-adjusted life year (DALY) averted. We evaluated the effect of uncertainty in baseline estimates through one-way and probabilistic sensitivity analyses.
  
  
  
  PrEP administered to pregnant and breastfeeding women in SSA was cost-effective. In a base case of 10,000 women, the administration of PrEP averted 381 HIV infections but resulted in 779 more preterm births. PrEP was more costly per person ($450 versus $117), but resulted in fewer disability-adjusted life years (DALYs) (3.15 versus 3.49). The incremental cost-effectiveness ratio of $965/DALY averted was below the recommended regional threshold for cost-effectiveness of $6462/DALY. Probabilistic sensitivity analyses demonstrated robustness of the model.
  
  
  
  Providing PrEP to pregnant and breastfeeding women in SSA is likely cost-effective, although more data are needed about adherence and safety. For populations at high risk of HIV acquisition, PrEP may be considered as part of a broader combination HIV prevention strategy.
authors.affiliation: *Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, NC; †Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC; ‡Department of Pediatrics and Child Health, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe; §Department of Psychiatry, John Stroger Hospital of Cook County, Chicago, IL; ‖Office of the Global AIDS Coordinator and Health Diplomacy, U.S. Department of State, Washington, DC; ¶Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD; and #Kelly Government Services, Contractor to Prevention Sciences Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.
authors.forename: Joan T
authors.initials: JT
authors.lastname: Price
authors.forename: Stephanie B
authors.initials: SB
authors.lastname: Wheeler
authors.forename: Lynda
authors.initials: L
authors.lastname: Stranix-Chibanda
authors.forename: Sybil G
authors.initials: SG
authors.lastname: Hosek
authors.forename: D Heather
authors.initials: DH
authors.lastname: Watts
authors.forename: George K
authors.initials: GK
authors.lastname: Siberry
authors.forename: Hans M L
authors.initials: HM
authors.lastname: Spiegel
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Stringer
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Chi
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D019380:Anti-HIV Agents / Q000191:economics / Q000627:therapeutic use*; D001942:Breast Feeding; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000517:prevention & control* / Q000635:transmission; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D065129:Pre-Exposure Prophylaxis / Q000191:economics*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy*
chemical_list: D019380:Anti-HIV Agents