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Dutch model finds PrEP for high-risk gay men is cost-effective at current prices and cost-saving at generic prices
Gus Cairns, 2016-09-27 10:10:00
A mathematical modelling
study based on the HIV epidemic in the Netherlands has found that daily PrEP
would be cost-effective even at current drug prices if it was targeted at gay
men at high risk of HIV infection.
In a base case where PrEP was 80% effective, 10% of
higher-risk gay men took it, current drug prices were used, and PrEP was taken every day, then PrEP’s cost per quality-adjusted life year (QALY) gained would be €11,000. This would fall to only €2,000 if PrEP was used on-demand and only half as much drug was
used. The model regards a cost per
of under €20,000 as cost-effective.
Daily PrEP would actually be
cost-saving (it would save more in terms of infections prevented than its
provision would cost) if drug prices fell 70% or more. If PrEP was taken on
demand, then prices would only have to fall by 30-40% for PrEP to save money. Applying generic rather than on-patent
prices turned PrEP in most scenarios from cost-effective to cost saving.
The model calculates these
savings over a 40-year time span. However the researchers add that most of the
savings achieved would actually take place in the first ten years, because that
is when the majority of HIV infections would be prevented.
There are several reasons why
this model, unlike some previous ones, finds that PrEP will be cost-effective
under most scenarios. Firstly it assumes a general effectiveness of PrEP of
80%, higher than many previous models that used more conservative figures
derived from studies like iPrEx, rather than this model, which uses the effectiveness seen in in the PROUD and
Secondly it assumes that PrEP
is taken by only 10% of the gay men in the two highest risk groups in the
Netherlands (men with 5-18 sexual partners in a year, and men with more than
18). “The actual uptake of PrEP is likely to be only a small percentage of
those at high risk,” the authors assert.
In terms of figures, this
implies 4,500 gay men taking PrEP in any one year, and the authors assume that
the average gay man will stay on PrEP for five years.
However even if 80% of men in
the two highest risk groups were taking PrEP – implying 36,000 men on PrEP in any
one year - this would only increase the cost per year of providing PrEP versus
not providing it by 40%, and it would remain cost-saving under many scenarios.
Thirdly its base case assumes
that the costs of antiretroviral therapy (ART) for HIV do not fall to the same
degree as PrEP. Even if the price of ART did fall to the same degree as the
price of PrEP, however, PrEP would still remain cost-effective. The cost per
QALY gained of on-demand PrEP would rise from €2000 to €4000 if both ART and PrEP prices fell by 70%. The authors say they consider this
unlikely, as ART is more likely to continue to feature new, patented and costlier drugs due to factors like resistance and long-term drug toxicity in an
ageing HIV-positive population.
Fourthly, and unlike many
cost-effectiveness studies, this one also takes account of preventing secondary
infections – the HIV transmissions that would otherwise be passed on by men who acquire HIV if they do not take PrEP. However even
if these are not taken into account, PrEP remains cost effective; at current
prices and if PrEP is taken daily, ignoring secondary infections would only increase
the cost per QALY gained from €11,000 to €13,100, and if it
was taken on-demand from €1980 to €2300.
even if the average duration of PrEP is doubled from five years to ten years,
the cost per QALY gained increases only from €10,800 to €11,400 for
daily PrEP and from €1900 to €2100 for on-demand PrEP.
base-case assumptions in the model include that the full current price of PrEP is
£7400 per year and that the cost of antiretroviral therapy and monitoring is €13,000 per year. It assumes ART
and monitoring costs €2500 more than
this in the first year after diagnosis. It adds in STI clinic or GP visit costs
of €124 for four
visits per year and €572 for HIV
clinic visits. (These figures are the actual current costs for drugs, monitoring
and clinic visits in the Netherlands.) It assumes that all HIV-positive people
start treatment on diagnosis and that the reduction in infectiousness caused by
ART is 80-96%. It does assume that people in in early infection are more
infectious, but also assumes that the period of raised infectiousness is quite
The cost of HIV treatment and
care in the Netherlands over the next 40 years is estimated at €8.3 billion. Providing a programme of daily PrEP, at current drug prices and
at 10% takeup, would add €423 million or 4.3% to this 40-year cost, or €93 million (0.5%) if it was taken on-demand. If the price of PrEP
was reduced by 70% relative to the price of ART then daily PrEP would actually
save €25 million and
on-demand PrEP would save €101 million.
most important determinants of PrEP cost-effectiveness in this model were, for
daily PrEP, its future fall in costs relative to ART and, for on-demand PrEP,
its absolute future fall in costs.
degree to which gay men were ‘targeted’ was also important; if more took PrEP
then the number of new HIV cases prevented per year would rise (i.e. incidence
would fall) relative to the 10% base case, but the cost per infection prevented
would also rise, because as time went by there would be fewer new cases to
while in other studies, “targeting” is the most important determinant of cost-effectiveness,
it runs second to drug price in this one. This is partly because the higher
effectiveness assumed by this study means that it becomes less crucial only to direct
PrEP at the very highest-risk gay men, who would even benefit as a population from
moderately-effective PrEP. However the model does not go into the cost
implications of providing PrEP to the more numerous lower-risk gay men with fewer
than five sexual partners a year.
the short-term costs of PrEP provision might be high,” the authors comment,
“PrEP could save HIV-related healthcare costs in the long run, especially when
the price of PrEP is reduced.”