Stanford University, California, USA.
Ann Intern Med. 2012 Apr 17;156(8):541-50. doi: 10.7326/0003-4819-156-8-201204170-00001.
A recent randomized, controlled trial showed that daily oral preexposure chemoprophylaxis (PrEP) was effective for HIV prevention in men who have sex with men (MSM). The Centers for Disease Control and Prevention recently provided interim guidance for PrEP in MSM at high risk for HIV. Previous studies did not reach a consistent estimate of its cost-effectiveness.
To estimate the effectiveness and cost-effectiveness of PrEP in MSM in the United States.
Dynamic model of HIV transmission and progression combined with a detailed economic analysis.
Published literature.
MSM aged 13 to 64 years in the United States.
Lifetime.
Societal.
PrEP was evaluated in both the general MSM population and in high-risk MSM and was assumed to reduce infection risk by 44% on the basis of clinical trial results.
New HIV infections, discounted quality-adjusted life-years (QALYs) and costs, and incremental cost-effectiveness ratios.
RESULTS OF BASE-CASE ANALYSIS: Initiating PrEP in 20% of MSM in the United States would reduce new HIV infections by an estimated 13% and result in a gain of 550,166 QALYs over 20 years at a cost of $172,091 per QALY gained. Initiating PrEP in a larger proportion of MSM would prevent more infections but at an increasing cost per QALY gained (up to $216,480 if all MSM receive PrEP). Preexposure chemoprophylaxis in only high-risk MSM can improve cost-effectiveness. For MSM with an average of 5 partners per year, PrEP costs approximately $50,000 per QALY gained. Providing PrEP to all high-risk MSM for 20 years would cost $75 billion more in health care-related costs than the status quo and $600,000 per HIV infection prevented, compared with incremental costs of $95 billion and $2 million per infection prevented for 20% coverage of all MSM.
PrEP in the general MSM population would cost less than $100,000 per QALY gained if the daily cost of antiretroviral drugs for PrEP was less than $15 or if PrEP efficacy was greater than 75%.
When examining PrEP in high-risk MSM, the investigators did not model a mix of low- and high-risk MSM because of lack of data on mixing patterns.
PrEP in the general MSM population could prevent a substantial number of HIV infections, but it is expensive. Use in high-risk MSM compares favorably with other interventions that are considered cost-effective but could result in annual PrEP expenditures of more than $4 billion.
National Institute on Drug Abuse, Department of Veterans Affairs, and National Institute of Allergy and Infectious Diseases.
最近的一项随机对照试验表明，每日口服暴露前预防（PrEP）对男男性行为者（MSM）的 HIV 预防有效。疾病控制与预防中心最近为 MSM 中 HIV 高危人群提供了 PrEP 的临时指导。先前的研究并未得出一致的成本效益估计。
估计美国 MSM 中 PrEP 的有效性和成本效益。
HIV 传播和进展的动态模型结合详细的经济分析。
已发表的文献。
年龄在 13 至 64 岁之间的美国 MSM。
终身。
社会。
根据临床试验结果，PrEP 评估了普通 MSM 人群和高危 MSM 人群中的效果，并假设其可降低 44%的感染风险。
新的 HIV 感染、贴现后的质量调整生命年（QALY）和成本，以及增量成本效益比。
在美国，20%的 MSM 开始接受 PrEP，预计将减少 13%的新 HIV 感染，并在 20 年内获得 550166 个 QALY，每获得一个 QALY 的成本为 172091 美元。如果 MSM 中更大比例的人开始接受 PrEP，则可以预防更多的感染，但每获得一个 QALY 的成本也会增加（如果所有 MSM 都接受 PrEP，则高达 216480 美元）。仅在高危 MSM 中使用 PrEP 可以提高成本效益。对于每年平均有 5 个性伴侣的 MSM，PrEP 的每个 QALY 成本约为 50000 美元。如果为所有高危 MSM 提供 20 年的 PrEP，将比现状增加 7500 亿美元的医疗保健相关费用，而每预防一例 HIV 感染的成本为 60 万美元，而对于所有 MSM 的 20%覆盖率，预防 20 年的增量成本分别为 950 亿美元和 200 万美元。
如果 PrEP 的每日抗逆转录病毒药物成本低于 15 美元，或者 PrEP 的疗效大于 75%，那么在普通 MSM 人群中进行 PrEP 的成本将低于 10 万美元/QALY。
在研究高危 MSM 中的 PrEP 时，由于缺乏混合模式的数据，研究人员没有对低危和高危 MSM 进行建模。
普通 MSM 人群中的 PrEP 可以预防大量 HIV 感染，但成本高昂。在高危 MSM 中使用 PrEP 与被认为具有成本效益的其他干预措施相比具有优势，但可能导致每年 PrEP 支出超过 40 亿美元。
国家药物滥用研究所、退伍军人事务部和国家过敏和传染病研究所。
