Table 3.
Reduction in Incidence, Difference in Response to First-Line ART, DALYs Averted, and Net DALYS Averted with Policies of PrEP for AGYW/FSW and PrEP for All
| Variation From Primary Analysis Assumptions | Reduction in Incidence, %a | Difference in Response to 1st-Line ART, %b | DALYs Averted, No.d | Difference in Cost Compared With no PrEP, US$ Million | Net DALYs averted, No. (%)d,e | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| PrEP for FSW/AGYWc | PrEP for all | PrEP for FSW/ AGYW | PrEP for all | PrEP for FSW/ AGYW | PrEP for all | PrEP for FSW/ AGYW | PrEP for all | PrEP for FSW/ AGYW | PrEP for all | |
| No variation, primary analysis | 25 (25–26) | 33 (32–33) | −1 (−1 to −1) | −3 (−2 to −3) | 9.6 (9.0–10.0) | 34.7 (33.7–35.7) | −$5.1 (−5.4 to −4.8) | −$15.0 (−15.6 to −14.4) | 16.3 (0) (15.3–16.7) | 54.7 (100) (54.0–56.4) |
| 100% adherence when on PrEP | 41 (39–42) | 48 (45–50) | −0 (0–0) | −2 (−2 to −2) | 20.6 (18.1–23.1) | 58.0 (51.6–64.4) | −$15.1 (−17.0 to −13.2) | −$35.0 (−38.9 to −31.1) | 40.7 (0) (36.1–45.3) | 105.6 (100) (94.9–116.3) |
| PrEP efficacy 80%, primary analysis 95% | 20 (18–22) | 27 (24–29) | −1 (−1 to 0) | −2 (−2 to −2) | 6.3 (4.5–8.1) | 26.3 (21.4–31.2) | −$1.2 (−2.8 to .4) | −$5.2 (−8.5 to −1.9) | 7.8 (5) (4.6–11.0) | 33.2 (95) (25.2–41.2) |
| Probability of restarting PrEP during a period with condomless sex partner(s)f having previously interrupted for a period with no new condomless sex partners 50%, primary analysis 95%h | 24 (22–26) | 32 (29–36) | −0 (−1 to 0) | −2 (−2 to −2) | 8.9 (6.7–11.1) | 32.2 (27.0–37.7) | −$4.0 (−5.9 to −2.1) | −$13.7 (−17.9 to −9.5) | 14.3 (3) (10.1–18.5) | 50.1 (97) (40.6–59.6) |
| Risk of stopping/interrupting PrEP per 3 mo, despite continuing to have new condomless sex partner(s) 10%, primary analysis 3%h | 20 (17–22) | 27 (25–29) | −2 (−1 to −2) | −1 (0 to −1) | 6.5 (5.2–7.8) | 26.1 (22.8–29.3) | −$3.2 (−4.4 to 2.0) | −$11.2 (−13.4 to −9.0) | 10.8 (0) (8.3–13.3) | 41.0 (100) (35.9–46.1) |
| 50% of people will not consider starting PrEP despite having condomless sex partner(s),f primary analysis 15%h | 23 (21–24) | 19 (18–22) | 0 (−1 to 0) | −1 (−1 to −1) | 6.9 (5.1–8.8) | 23.1 (20.2–26.0) | −$4.8 (−5.9 to −3.7) | −$11.4 (−13.4 to −9.2) | 13.3 (0) (10.6–16.0) | 38.3 (100) (33.6–43.0) |
| Lower PrEP uptake and retention, as reflected by simultaneous variationsh | 17 (16–18) | 14 (13–15) | 0 (−1 to 0) | −1 (−1 to −1) | 5.0 (3.6–6.4) | 16.6 (15.0–18.2) | −$2.5 (−3.3 to −1.7) | −$8.2 (−9.0 to −7.4) | 8.3 (0) (6.3–10.3) | 27.5 (100) (25.5–29.5) |
| Efavirenz as 1st-line ART in all, primary analysis dolutegravir as 1st-line in all | 21 (20–22) | 24 (22–25) | −5 (−5 to −5) | −14 (−14 to −14) | −0.8i (−2.7 to 1.1) | 10.0 (6.4–13.6) | $1.6 (.4–2.8) | $0.9 (−1.3 to 3.1) | −3.0k (6) (−7.2 to .2) | 8.9 (60) (3.1–14.7) |
| PrEP has 0.5-fold lower efficacy against virus with K65R regardless of presence of M184V | 25 (24–27) | 33 (31–35) | −1 (−1 to 0) | −3 (−3 to −2) | 9.2 (7.9–10.5) | 31.6 (28.1–35.1) | −$4.6 (−5.9 to −3.3) | −$13.6 (−15.5 to −11.7) | 15.3 (1) (13.4–17.2) | 49.6 (99) (44.5–55.0) |
| PrEP has zero efficacy against virus containing both M184V and K65R mutations | 24 (23–26) | 29 (26–30) | −1 (−1 to −1) | −4 (−4 to −3) | 7.4 (5.9–8.9) | 25.4 (22.0–28.8) | −$3.3 (−4.8 to −1.8) | −$4.7 (−8.3 to −1.1) | 11.8 (6) (8.8–14.8) | 31.7 (94) (25.0–38.4) |
| PrEP clinic visits and 6-mo HIV testing, primary analysis 3 mo | 25 (24–27) | 34 (32–35) | −1 (−1 to 0) | −3 (−3 to −2) | 8.9 (7.9–9.9) | 32.9 (30.0–35.5) | −$5.8 (−6.7 to −4.9) | −$17.8 (−19.7 to −15.9) | 16.2 (0) (14.4–18.0) | 56.6 (100) (51.0–61.2) |
| HIV testing uses antigen/antibody tests, primary analysis antibody onlyg | 25 (23–26) | 33 (31–35) | −1 (−1 to 0) | −2 (−2 to −2) | 9.4 (8.1–10.7) | 35.9 (33.3–38.5) | −$5.3 (−6.2 to −4.4) | −$16.3 (−18.1 to −14.5) | 16.5 (0) (14.3–18.7) | 57.6 (100) (53.2–62.0) |
| People on PrEP have 2-fold increased numbers of condomless sex partners due to taking PrEP, primary analysis no increase | 16 (15–17) | 15 (14–16) | −1 (−1 to −1) | −4 (−4 to −4) | −3.2j (−4.2 to −2.2) | 4.9 (2.9–6.9) | $6.3 (5.5–7.1) | $12.2 (10.8–13.6) | −11.7k (5) (−13.4 to −10.0) | −11.3k (27) (−14.7 to −6.9) |
| One 3-mo period of PrEP while no condomless sex is experienced, not even with a primary partner, for each 3-mo period of PrEP while having condomless sex partners,f primary analysis PrEP not used in 3-mo periods with no new condomless sex partnersi | As primary analysis | As primary analysis | As primary analysis | As primary analysis | As primary analysis | As primary analysis | $0.7 (−0.2 to 1.6) | $0.8 (.4–1.2) | 8.6 (4) (7.9–9.3) | 33.7 (95) (31.9–35.5) |
| 7% discount rate, primary analysis 3%i | As primary analysis | As primary analysis | As primary analysis | As primary analysis | 2.7 (2.5–2.9) | 10.6 (10.2–11.0) | −$0.3 (−0.5 to −0.1) | −$1.8 (1.5–2.1) | 3.1 (2) (2.8–3.4) | 13.0 (98) (12.5–13.5) |
| Plausible future reduced PrEP costs: 4 HIV tests/y $3 each, 1 PrEP clinic visit/y, PrEP drug $35–$57/y, primary analysis $136/yi | As primary analysis | As primary analysis | As primary analysis | As primary analysis | As primary analysis | As primary analysis | −$8.5 (−8.8 to −8.2) | −$24.5 (−25.1 to −23.9) | 20.9 (0) (19.2–22.6) | 67.4 (100) (66.7–68/1) |
Data are mean over 50 years (20 years for HIV incidencea and difference in response to first-line ARTb) and 95% confidence interval.
Abbreviations: AGYW, adolescent girls and young women; ART, antiretroviral therapy; DALY, disability-adjusted life-year; FSW, female sex workers; HIV, human immunodeficiency virus; PrEP, preexposure prophylaxis.
aReduction in incidence is shown over a shorter time period than 50 years as a mechanism of effect on DALYs is via reduction in new infections.
bOf people who started ART 1 year ago and are still on ART, proportion with VL <500 copies/mL, the differences is due to difference in drug-resistance outcomes and this output is shown over a shorter time period than 50 years as drug resistance is a mechanism of effect on DALYs.
cReduction in incidence relates in AGYW only in relation to PrEP for AGW and to all aged 15–64 y for PrEP for all.
dDALYS and net DALYs averted in whole population in 1000s; net DALYs based on cost-effectiveness threshold of $750.
eOr a period percent of scenarios in which PrEP policy is the cost-effective policy choice. In the remainder of scenarios no PrEP introduction is the most cost-effective policy.
fPeriod with a primary on-going condomless sex partner who is diagnosed with HIV but off ART.
gTest cost assumed the same as antibody-only test.
hLower PrEP uptake and retention, as reflected by simultaneous variations in indicated items given in rows: 50% of people will not consider starting PrEP despite having condomless sex partner(s); risk of stopping/interrupting PrEP per 3 mo; and probability of restarting PrEP during a period with condomless sex partner(s).
iUses base runs.
jDALYs not averted.
kNet DALYs not averted.
Percentage of scenarios in which policy is cost-effective choice considering only no PrEP and PrEP for FSW