Potential impact and cost-effectiveness of condomless-sex-concentrated PrEP in KwaZulu-Natal accounting for drug resistance

SOURCE: Journal of Infectious Diseases
OUTPUT TYPE: Journal Article
PUBLICATION YEAR: 2019
TITLE AUTHOR(S): A.N.Phillips, V.Cambiano, L.Johnson, F.Nakagawa, R.Homan, G.Meyer-Rath, T.Rehle, F.Tanser, S.Moyo, M.Shahmanesh, D.Castor, E.Russell, L.Jamieson, L.Bansi-Matharu, A.Shrouf, R.V.Barnabas, U.M.Parikh, J.W.Mellors, P.Revill
KEYWORDS: CONDOM USE, DRUG RESISTANCE, HIV/AIDS, ORAL PRE-EXPOSURE PROPHYLAXIS (PrEP), SEXUAL BEHAVIOUR
DEPARTMENT: Human and Social Capabilities (HSC)
Print: HSRC Library: shelf number 11214
HANDLE: 20.500.11910/15171
URI: http://hdl.handle.net/20.500.11910/15171

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Abstract

Oral preexposure prophylaxis (PrEP) in the form of tenofovir-disoproxil-fumarate/emtricitabine is being implemented in selected sites in South Africa. Addressing outstanding questions on PrEP cost-effectiveness can inform further implementation. We calibrated an individual-based model to KwaZulu-Natal to predict the impact and cost-effectiveness of PrEP, with use concentrated in periods of condomless sex, accounting for effects on drug resistance. We consider (1) PrEP availability for adolescent girls and young women aged 15-24 years and female sex workers, and (2) availability for everyone aged 15-64 years. Our primary analysis represents a level of PrEP use hypothesized to be attainable by future PrEP programs. In the context of PrEP use in adults aged 15-64 years, there was a predicted 33% reduction in incidence and 36% reduction in women aged 15-24 years. PrEP was cost-effective, including in a range of sensitivity analyses, although with substantially reduced (cost) effectiveness under a policy of ART initiation with efavirenz- rather than dolutegravir-based regimens due to PrEP undermining ART effectiveness by increasing HIV drug resistance. PrEP use concentrated during time periods of condomless sex has the potential to substantively impact HIV incidence and be cost-effective.