Kaftan David, Sharma Monisha, Resar Danielle, Milali Masabho, Mudimu Edinah, Wu Linxuan, Arrouzet Cory, Platais Ingrida, Kim Hae-Young, Jenkins Sarah, Bershteyn Anna
Department of Population Health, New York University Grossman School of Medicine, New York, New York, 10016, USA.
Department of Global Health, University of Washington, Seattle, Washington, USA.
J Int AIDS Soc. 2025 Feb;28(2):e26427. doi: 10.1002/jia2.26427.
Affordable HIV prevention tools are needed in Eastern and Southern Africa (ESA). Several promising long-acting pre-exposure prophylaxis (LA-PrEP) products are available or in development. However, ESA settings face severe healthcare resource constraints. We aimed to estimate the threshold price at which LA-PrEP products could be cost-effective in three ESA settings.
We adapted an agent-based model, EMOD-HIV, to simulate LA-PrEP (monthly oral, 2- and 6-monthly injectable) rollout in South Africa, Zimbabwe and Kenya. Due to uncertainties about LA-PrEP use, we examined a range of coverages (5%-20% of HIV-negative sexually active adults) and extents to which LA-PrEP use will be concentrated among those most at risk (prioritized rollout from higher- to lower-risk groups vs. uniform rollout among sexually active adults). To evaluate a 20-year commitment to LA-PrEP delivery, we assumed LA-PrEP was scaled up to target coverage from 2025 to 2030 and maintained at target levels before ending in 2045. We estimated maximum per-dose and per-year LA-PrEP costs that achieve cost-effectiveness (<US$500 per disability-adjusted life-year averted) over 35 years (until 2060), compared to a scenario of daily oral PrEP only. Sensitivity analyses varied PrEP scale-up speeds and eligible populations.
Risk-prioritized LA-PrEP for 5% of adults was projected to avert 11-21% of HIV acquisitions across settings, with 3-5 times more HIV acquisitions averted and 3-5 times higher maximum cost compared to non-prioritized rollout. Six-monthly injectable PrEP supported the highest per-dose cost: in the scenario with the most cost-effective LA-PrEP use (5% risk-prioritized rollout), the maximum per-dose price in South Africa was $52.99 (95% CI: $48.82-$57.21), in Zimbabwe $14.64 (95% CI: $12.04-$17.38) and in western Kenya $7.50 (95% CI: $6.73-$8.27). For monthly oral PrEP, corresponding per-dose costs were $5.02 (95% CI: $4.67-$5.37), $1.45 (95% CI: $1.10-$1.79) and $0.87 (95% CI: $0.80-$0.93). Results were sensitive to eligible population and prioritization, and moderately sensitive to scale-up speed and product effectiveness.
LA-PrEP is likely to require reduced pricing and/or risk-prioritized rollout to be cost-effective in ESA.
东部和南部非洲（ESA）地区需要价格可承受的艾滋病毒预防工具。有几种很有前景的长效暴露前预防（LA-PrEP）产品已经上市或正在研发中。然而，ESA地区的医疗资源严重受限。我们旨在估算在ESA地区的三种环境中，LA-PrEP产品具有成本效益的阈值价格。
我们采用了一种基于主体的模型EMOD-HIV，来模拟在南非、津巴布韦和肯尼亚推出LA-PrEP（每月口服、每2个月和每6个月注射一次）的情况。由于LA-PrEP使用情况存在不确定性，我们研究了一系列覆盖率（占艾滋病毒阴性性活跃成年人的5%-20%）以及LA-PrEP使用在风险最高人群中的集中程度（从高风险组到低风险组优先推广与性活跃成年人中均匀推广）。为了评估对LA-PrEP交付的20年承诺，我们假设LA-PrEP从2025年到2030年扩大规模至目标覆盖率，并在2045年结束前维持在目标水平。与仅每日口服PrEP的情景相比，我们估算了在35年（直至2060年）内实现成本效益（每避免一个伤残调整生命年成本<500美元）的LA-PrEP每剂和每年的最高成本。敏感性分析改变了PrEP扩大规模的速度和符合条件的人群。
预计为5%的成年人进行风险优先的LA-PrEP推广，在所有环境中可避免11%-21%的艾滋病毒感染，与非优先推广相比，避免的艾滋病毒感染多3-5倍，最高成本高3-5倍。每6个月注射一次的PrEP支持最高的每剂成本：在LA-PrEP使用最具成本效益的情景（5%风险优先推广）中，南非的最高每剂价格为52.99美元（95%置信区间：48.82美元-57.21美元），津巴布韦为14.64美元（95%置信区间：12.04美元-17.38美元），肯尼亚西部为7.50美元（95%置信区间：6.73美元-8.27美元）。对于每月口服PrEP，相应的每剂成本分别为5.02美元（95%置信区间：4.67美元-5.37美元）、1.45美元（95%置信区间：1.10美元-1.79美元）和0.87美元（95%置信区间：0.80美元-0.93美元）。结果对符合条件的人群和优先顺序敏感，对扩大规模速度和产品有效性中度敏感。
在ESA地区，LA-PrEP可能需要降低价格和/或风险优先推广才能具有成本效益。
