Cost-effectiveness of PrEP in HIV/AIDS control in Zambia

A stochastic league approach

Brooke E. Nichols, Rob Baltussen, Janneke H. Van Dijk, Philip E Thuma, Jan L. Nouwen, Charles A B Boucher, David A M C Van De Vijver

Research output: Contribution to journalArticle

Abstract

Background: Earlier antiretroviral therapy initiation and pre-exposure prophylaxis (PrEP) prevent HIV, although at a substantial cost. We use mathematical modeling to compare the cost-effectiveness and economic affordability of antiretroviral-based prevention strategies in rural Macha, Zambia. Methods: We compare the epidemiological impact and cost-effectiveness over 40 years of a baseline scenario (treatment initiation at CD4 <350 cells/μL) with treatment initiation at CD4 <500 cells per microliter, and PrEP (prioritized to the most sexually active, or nonprioritized). A strategy is cost effective when the incremental cost-effectiveness ratio (ICER) is <$3480 (<3 times Zambian per capita GDP). Stochastic league tables then predict the optimal intervention per budget level. Results: All scenarios will reduce the prevalence from 6.2% (interquartile range, 5.8%-6.6%) in 2014 to about 1% after 40 years. Compared with the baseline, 16% of infections will be averted with prioritized PrEP plus treatment at CD4 <350, 34% with treatment at CD4 <500, and 59% with nonprioritized PrEP plus treatment at CD4 <500. Only treating at CD4 <500 is cost effective: ICER of $62 ($46-$75). Nonprioritized PrEP plus treating at CD4 <500 is borderline cost effective: ICER of $5861 ($3959-$8483). Initiating treatment at CD4 <500 requires a budget increase from $20 million to $25 million over 40 years, with a 96.7% probability of being the optimal intervention. PrEP should only be considered when the budget exceeds $180 million. Conclusions: Treatment initiation at CD4 <500 is a cost-effective HIV prevention approach that will require a modest increase in budget. Although adding PrEP will avert more infections, it is not economically feasible, as it requires a 10-fold increase in budget.

Original languageEnglish (US)
Pages (from-to)221-228
Number of pages8
JournalJournal of Acquired Immune Deficiency Syndromes
Volume66
Issue number2
DOIs
StatePublished - Jun 1 2014
Externally publishedYes

Fingerprint

Zambia
Cost-Benefit Analysis
Acquired Immunodeficiency Syndrome
Budgets
HIV
Costs and Cost Analysis
Therapeutics
Secondary Prevention
Infection
Pre-Exposure Prophylaxis
Economics

Keywords

  • cost-effectiveness
  • pre-exposure prophylaxis
  • stochastic league tables
  • treatment as prevention

ASJC Scopus subject areas

  • Pharmacology (medical)
  • Infectious Diseases

Cite this

Nichols, B. E., Baltussen, R., Van Dijk, J. H., Thuma, P. E., Nouwen, J. L., Boucher, C. A. B., & Van De Vijver, D. A. M. C. (2014). Cost-effectiveness of PrEP in HIV/AIDS control in Zambia: A stochastic league approach. Journal of Acquired Immune Deficiency Syndromes, 66(2), 221-228. https://doi.org/10.1097/QAI.0000000000000145

Cost-effectiveness of PrEP in HIV/AIDS control in Zambia : A stochastic league approach. / Nichols, Brooke E.; Baltussen, Rob; Van Dijk, Janneke H.; Thuma, Philip E; Nouwen, Jan L.; Boucher, Charles A B; Van De Vijver, David A M C.

In: Journal of Acquired Immune Deficiency Syndromes, Vol. 66, No. 2, 01.06.2014, p. 221-228.

Research output: Contribution to journalArticle

Nichols, BE, Baltussen, R, Van Dijk, JH, Thuma, PE, Nouwen, JL, Boucher, CAB & Van De Vijver, DAMC 2014, 'Cost-effectiveness of PrEP in HIV/AIDS control in Zambia: A stochastic league approach', Journal of Acquired Immune Deficiency Syndromes, vol. 66, no. 2, pp. 221-228. https://doi.org/10.1097/QAI.0000000000000145
Nichols, Brooke E. ; Baltussen, Rob ; Van Dijk, Janneke H. ; Thuma, Philip E ; Nouwen, Jan L. ; Boucher, Charles A B ; Van De Vijver, David A M C. / Cost-effectiveness of PrEP in HIV/AIDS control in Zambia : A stochastic league approach. In: Journal of Acquired Immune Deficiency Syndromes. 2014 ; Vol. 66, No. 2. pp. 221-228.
@article{4c32ab5d95224359ad120fe1765812a3,
title = "Cost-effectiveness of PrEP in HIV/AIDS control in Zambia: A stochastic league approach",
abstract = "Background: Earlier antiretroviral therapy initiation and pre-exposure prophylaxis (PrEP) prevent HIV, although at a substantial cost. We use mathematical modeling to compare the cost-effectiveness and economic affordability of antiretroviral-based prevention strategies in rural Macha, Zambia. Methods: We compare the epidemiological impact and cost-effectiveness over 40 years of a baseline scenario (treatment initiation at CD4 <350 cells/μL) with treatment initiation at CD4 <500 cells per microliter, and PrEP (prioritized to the most sexually active, or nonprioritized). A strategy is cost effective when the incremental cost-effectiveness ratio (ICER) is <$3480 (<3 times Zambian per capita GDP). Stochastic league tables then predict the optimal intervention per budget level. Results: All scenarios will reduce the prevalence from 6.2{\%} (interquartile range, 5.8{\%}-6.6{\%}) in 2014 to about 1{\%} after 40 years. Compared with the baseline, 16{\%} of infections will be averted with prioritized PrEP plus treatment at CD4 <350, 34{\%} with treatment at CD4 <500, and 59{\%} with nonprioritized PrEP plus treatment at CD4 <500. Only treating at CD4 <500 is cost effective: ICER of $62 ($46-$75). Nonprioritized PrEP plus treating at CD4 <500 is borderline cost effective: ICER of $5861 ($3959-$8483). Initiating treatment at CD4 <500 requires a budget increase from $20 million to $25 million over 40 years, with a 96.7{\%} probability of being the optimal intervention. PrEP should only be considered when the budget exceeds $180 million. Conclusions: Treatment initiation at CD4 <500 is a cost-effective HIV prevention approach that will require a modest increase in budget. Although adding PrEP will avert more infections, it is not economically feasible, as it requires a 10-fold increase in budget.",
keywords = "cost-effectiveness, pre-exposure prophylaxis, stochastic league tables, treatment as prevention",
author = "Nichols, {Brooke E.} and Rob Baltussen and {Van Dijk}, {Janneke H.} and Thuma, {Philip E} and Nouwen, {Jan L.} and Boucher, {Charles A B} and {Van De Vijver}, {David A M C}",
year = "2014",
month = "6",
day = "1",
doi = "10.1097/QAI.0000000000000145",
language = "English (US)",
volume = "66",
pages = "221--228",
journal = "Journal of Acquired Immune Deficiency Syndromes",
issn = "1525-4135",
publisher = "Lippincott Williams and Wilkins",
number = "2",

}

TY - JOUR

T1 - Cost-effectiveness of PrEP in HIV/AIDS control in Zambia

T2 - A stochastic league approach

AU - Nichols, Brooke E.

AU - Baltussen, Rob

AU - Van Dijk, Janneke H.

AU - Thuma, Philip E

AU - Nouwen, Jan L.

AU - Boucher, Charles A B

AU - Van De Vijver, David A M C

PY - 2014/6/1

Y1 - 2014/6/1

N2 - Background: Earlier antiretroviral therapy initiation and pre-exposure prophylaxis (PrEP) prevent HIV, although at a substantial cost. We use mathematical modeling to compare the cost-effectiveness and economic affordability of antiretroviral-based prevention strategies in rural Macha, Zambia. Methods: We compare the epidemiological impact and cost-effectiveness over 40 years of a baseline scenario (treatment initiation at CD4 <350 cells/μL) with treatment initiation at CD4 <500 cells per microliter, and PrEP (prioritized to the most sexually active, or nonprioritized). A strategy is cost effective when the incremental cost-effectiveness ratio (ICER) is <$3480 (<3 times Zambian per capita GDP). Stochastic league tables then predict the optimal intervention per budget level. Results: All scenarios will reduce the prevalence from 6.2% (interquartile range, 5.8%-6.6%) in 2014 to about 1% after 40 years. Compared with the baseline, 16% of infections will be averted with prioritized PrEP plus treatment at CD4 <350, 34% with treatment at CD4 <500, and 59% with nonprioritized PrEP plus treatment at CD4 <500. Only treating at CD4 <500 is cost effective: ICER of $62 ($46-$75). Nonprioritized PrEP plus treating at CD4 <500 is borderline cost effective: ICER of $5861 ($3959-$8483). Initiating treatment at CD4 <500 requires a budget increase from $20 million to $25 million over 40 years, with a 96.7% probability of being the optimal intervention. PrEP should only be considered when the budget exceeds $180 million. Conclusions: Treatment initiation at CD4 <500 is a cost-effective HIV prevention approach that will require a modest increase in budget. Although adding PrEP will avert more infections, it is not economically feasible, as it requires a 10-fold increase in budget.

AB - Background: Earlier antiretroviral therapy initiation and pre-exposure prophylaxis (PrEP) prevent HIV, although at a substantial cost. We use mathematical modeling to compare the cost-effectiveness and economic affordability of antiretroviral-based prevention strategies in rural Macha, Zambia. Methods: We compare the epidemiological impact and cost-effectiveness over 40 years of a baseline scenario (treatment initiation at CD4 <350 cells/μL) with treatment initiation at CD4 <500 cells per microliter, and PrEP (prioritized to the most sexually active, or nonprioritized). A strategy is cost effective when the incremental cost-effectiveness ratio (ICER) is <$3480 (<3 times Zambian per capita GDP). Stochastic league tables then predict the optimal intervention per budget level. Results: All scenarios will reduce the prevalence from 6.2% (interquartile range, 5.8%-6.6%) in 2014 to about 1% after 40 years. Compared with the baseline, 16% of infections will be averted with prioritized PrEP plus treatment at CD4 <350, 34% with treatment at CD4 <500, and 59% with nonprioritized PrEP plus treatment at CD4 <500. Only treating at CD4 <500 is cost effective: ICER of $62 ($46-$75). Nonprioritized PrEP plus treating at CD4 <500 is borderline cost effective: ICER of $5861 ($3959-$8483). Initiating treatment at CD4 <500 requires a budget increase from $20 million to $25 million over 40 years, with a 96.7% probability of being the optimal intervention. PrEP should only be considered when the budget exceeds $180 million. Conclusions: Treatment initiation at CD4 <500 is a cost-effective HIV prevention approach that will require a modest increase in budget. Although adding PrEP will avert more infections, it is not economically feasible, as it requires a 10-fold increase in budget.

KW - cost-effectiveness

KW - pre-exposure prophylaxis

KW - stochastic league tables

KW - treatment as prevention

UR - http://www.scopus.com/inward/record.url?scp=84901491559&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84901491559&partnerID=8YFLogxK

U2 - 10.1097/QAI.0000000000000145

DO - 10.1097/QAI.0000000000000145

M3 - Article

VL - 66

SP - 221

EP - 228

JO - Journal of Acquired Immune Deficiency Syndromes

JF - Journal of Acquired Immune Deficiency Syndromes

SN - 1525-4135

IS - 2

ER -