PrEP for High-Risk MSM in the United States Judged Cost-Effective

Pre-exposure prophylaxis (PrEP) with daily antiretrovirals to prevent HIV acquisition in US men who have sex with men (MSM) would be expensive but would be cost-effective if limited to men who have an average of 5 sex partners yearly, according to results of a cost-benefit analysis. If extended to a wider group of US MSM, PrEP would not be cost-effective.

An international placebo-controlled trial including MSM in the United States determined that PrEP with tenofovir/emtricitabine would lower the risk of HIV acquisition by 44% in sexually active men (Grant RM, et al. N Engl J Med. 2010; 363:2587-2599). HIV acquisition risk was lower in MSM who took their daily antiretrovirals regularly. PrEP has also proved effective in heterosexual women and men in Africa.

Cost-effectiveness means that a strategy is “a good value” relative to other accepted strategies or the strategy it may replace. It does not necessarily mean a strategy is inexpensive or can be afforded by a country’s healthcare system.

This analysis used a dynamic model of HIV transmission and progression and a detailed economic analysis based on published data. The target population consisted of MSM from 13 to 64 years old living in the United States. The model assumed that PrEP would lower the risk of HIV acquisition by 44% and it considered the impact of PrEP over the lifetime of these men.

Starting PrEP in 20% of MSM in the United States would cut new HIV infections by 13% and result in a gain of 550,166 quality-adjusted life years (QALYs) over 20 years for $172,091 per QALY gained. Starting PrEP in more MSM would prevent more HIV infections but at a higher cost per QALY gained (up to $216,480 if all MSM received PrEP).

If PrEP were limited to high-risk MSM—those with an average of 5 sex partners yearly—PrEP would cost about $50,000 per QALY gained. Providing PrEP to these men for 20 years would cost $75 billion more in health-related costs than not providing PrEP and $600,000 per HIV infection prevented. In contrast, providing PrEP to 20% of all MSM for 20 years would cost $95 billion and $2 million per infection prevented.

The researchers conclude that PrEP for high-risk MSM in the United States “compares favorably with other interventions that are considered cost-effective but could result in annual PrEP expenditures of more than $4 billion.”

If PrEP lowered the risk of HIV acquisition more than 44%, as it did in adherent men in the MSM PrEP trial, it would be more cost-effective.

Source: Jessie L. Juusola, Margaret L. Brandeau, Douglas K. Owens, Eran Bendavid. The cost-effectiveness of preexposure prophylaxis for HIV prevention in the United States in men who have sex with men. Annals of Internal Medicine. 2012; 156: 541-550.

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Written by Mark Mascolini on behalf of the International AIDS Society