The cost-effectiveness of Pre-Exposure Prophylaxis in HIV Prevention: Analysis from A Multicentre Intervention in Northern Nigeria
Main Article Content
Abstract
Background: Pre-exposure prophylaxis (PrEP) is recommended for people at substantial risk of acquiring HIV to prevent new infections. The Nigeria PEPFAR program through USAID funded the implementation of PrEP for Key Population (KP) groups including Men Who Have Sex with Men (MSM), People who inject drugs (PWIDS), and Female sex Workers (FSW) in July 2020. We assessed the number of new infections averted and the financial resources saved because of this intervention.
Methodology: HIV-negative clients from the key population community in North- East Nigeria eligible for PrEP were enrolled over a 7-month period (July 2020 – February 2021). Eligibility criteria used include being at substantial risk for HIV infection based on a screening test administered. The person-month was calculated by using the duration the participants were retained on PrEP. The incidence 15.4/100 person-years of HIV among MSM at high risk of HIV infection in the TRUST study conducted in Nigeria was used to calculate the expected positive cases if PrEP was not provided for those enrolled using the formula (15.4/100 * X) where X is number of person-years. We compared the expected positive to the actual positive seen among KPs while on PrEP within the study period. The cost-effectiveness of being on PrEP was calculated by multiplying the standard cost per HIV infection averted ($13, 267 per HIV infection averted) by the No of HIV averted.
Results: We enrolled a total of 1,197 eligible HIV-negative KPs within the study period (189 were retained for seven months, 407 for four months, 585 for 3 months, and 18 for 1 month). A total of 4722 person-months (394 person-years) were accumulated over the period of the study. Using the incidence of 15.4/100 person-years, the expected positive cases if PrEP was not provided was 61 (15.4/100 *394). With the use PrEP, no client seroconverted to be HIV positive. This means that within the 7-month period, 61 HIV infections were averted. At the cost of $13,267 per HIV infection averted for PrEP, the project saved $809,287 for averting 61 HIV infections in seven months of using PrEP among HIV-negative KPs involved in high-risk behaviors.
Conclusion: This study shows that PrEP is effective in averting new infections among key population groups. Placing high-risk groups such as KPs on PrEP is cost-effective due to the money saved from new infections averted. Increased funding for proven and innovative strategies on PrEP enrolment, retention, and adherence of eligible clients should be expanded for KPs.
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
2. UNAIDS (2021) Pre-exposure prophylaxis (PrEP). Accessed from https://www.unaids.org/en/resources/presscentre/featurestories/2021/february/pre-exposure-prophylaxis-prep
3. Grubb, et al (2014) Maximizing the benefits of antiretroviral therapy for key affected populations. Doi: 10.7448/IAS.17.1.19320. J Int AIDS Soc.; 17(1): 19320
4. World Health Organisation (2018) Focus on Key Population in National HIV Strategic Plans in The African Region. © World Health Organization 2018 available at https://apps.who.int/iris/bitstream/handle/10665/275494/WHO-AF-CDS-HIV-02.2018-eng.pdf?ua=1
5. Lo, J., Nwafor, S.U., Schwitters, A.M., Mitchell, A., Sebastian, V., Stafford, K.A., Ezirim, I., Charurat, M. and McIntyre, A.F. (2021) Key Population Hotspots in Nigeria for Targeted HIV Program Planning: Mapping, Validation, and Reconciliation. JMIR Public Health Surveill. 2021 Feb 22;7(2): e25623. doi: 10.2196/25623. PMID: 33616537; PMCID: PMC7939933.
6. Stone, et al (2021) Estimating the Contribution of key populations towards HIV Transmission in South Africa. JIAS. https://doi.org/10.1002/jia2.25650.
7. Bekker, L.G., Beyrer, C., Quinn, T.C. (2012)
Behavioural and biomedical combination strategies for HIV prevention. Cold Spring Harb Perspect Med. 1;2(8): a007435. doi: 10.1101/cshperspect. a007435. PMID: 22908192; PMCID: PMC3405825.
8. Hillis, A., Germain, J., Hope, V., McVeigh, J. and Van Hou, M.C. (2020) Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Men Who Have Sex with Men (MSM): A Scoping Review on PrEP Service Delivery and Programming. AIDS Behav. 24(11): 3056–3070. doi: 10.1007/s10461-020-02855-9
9. WHO (2015) WHO expands recommendation on oral pre-exposure prophylaxis of HIV infection (PrEP). Retrieved from https://www.who.int/hiv/mediacentre/news/prep-guideline-announcement/en/
10. PEPFAR (2021) Nigeria. Accessed from https://www.state.gov/pepfar/countries/ng/
11. Trager, M., Schroeder, S., Wright, E., et al. (2018) Effects of pre-exposure prophylaxis for the prevention of human immunodeficiency virus infection on sexual risk behaviour in men who have sex with men: a systematic review and meta-analysis. Clin Infect Dis.;67(5):676–686.
12. Cassell, M. M., Halperin, D. T., Shelton, J. D., Stanton, D., and Weiss, H. (2016) Optimizing the benefits of pre-exposure prophylaxis (PrEP) for men who have sex with men (MSM) in the United States. Social Science & Medicine, 151, 209-218. Doi: 10.1016/j.socscimed.2015.12.032
13. World Health Organization (2015) WHO expands recommendation on oral pre-exposure prophylaxis of HIV infection (PrEP). Retrieved from https://www.who.int/hiv/mediacentre/news/prep-recommendation-press-release/en/
14. Ndebele, W., Celum, C., and Bautista-Arredondo, S. (2020) The potential impact and cost-effectiveness of offering preexposure prophylaxis for HIV prevention among high-risk heterosexuals in Zimbabwe: A modelling study. PLoS Medicine, 17(10), e1003312. Doi: 10.1371/journal.pmed.1003312
15. Case, K.K., Gomez, G.B. and Hallett, T.B. (2019) The impact, cost, and cost-effectiveness of oral pre-exposure prophylaxis in sub-Saharan Africa: a scoping review of modelling contributions and way forward. Journal of the International AIDS Society https://doi.org/10.1002/jia2.25390
16. Schackman, Bruce R., Eggman, Ashley, A. (2012) Cost–effectiveness of pre-exposure prophylaxis for HIV: a review. Current Opinion in HIV and AIDS 7(6):p 587-592 | DOI: 10.1097/COH.0b013e3283582c8b
17. Agaba, P. A., Meloni, S. T., Suleiman, A., Agbaji, O. O., Ekeh, P. N., Job, G. and Kanki, P. J. (2020) Feasibility and acceptability of providing pre-exposure prophylaxis to female sex workers and men who have sex with men in Nigeria. Journal of the International AIDS Society, 23(S1), e25445. Doi: 10.1002/jia2.25445
18. Oduwole, A. A., Adebanjo, S., Eluwa, G. I., Ahonsi, B. A., Fadeyi, A., and Kehinde, K. (2021) Cost-effectiveness analysis of HIV prevention strategies in Nigeria: Evidence from the EMPOWER trial. PloS One, 16(3), e0248464. Doi: 10.1371/journal.pone.0248464
19. Wirtz, A. L., Kamba, D., Jumbe, V., Trapence, G., Gubin, R., Umar, E. & Beyrer, C. (2019) A systematic review of cost-effectiveness of pre-exposure prophylaxis for HIV prevention in sub-Saharan Africa. Journal of the International AIDS Society, 22(1)
20. Beyrer, C., McCormack, S. and Grulich, A. (2022) Pre-Exposure Prophylaxis for HIV Infection as a Public Health Tool. J Law Med Ethics ;50(S1):24-28. Doi: 10.1017/jme.2022.31. PMID: 35902085; PMCID: PMC9341191.
21. Vu L, Adebajo S, Tun W, Sheehy M, Karlyn A, Njab J, Azeez A, Ahonsi B. High HIV prevalence among men who have sex with men in Nigeria: implications for combination prevention. J Acquir Immune Defic Syndr. 2013 Jun 1;63(2):221-7. doi: 10.1097/QAI.0b013e31828a3e60. PMID: 23406978.
22. NIH National Library of Medicine (2016). Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations – 2016 Update
23. Moyo E, Moyo P, Murewanhema G, Mhango M, Chitungo I, Dzinamarira T. Key populations and Sub-Saharan Africa's HIV response. Front Public Health. 2023 May 16;11:1079990. doi: 10.3389/fpubh.2023.1079990. PMID: 37261232; PMCID: PMC10229049.
24. 6. Jin H, Restar A, Beyrer C. Overview of the epidemiological conditions of HIV among key populations in Africa. J Int AIDS Soc. (2021) 24(Suppl 3):e25716. 10.1002/jia2.25716
25. Eshikumo P, Awuor P, Blanco N, Lavoie MC, Whittington A, Wangusi R, Kimani J, Ngunu C, Omai J, Obwiri W, Mutisya I, Koech E. Factors Associated with Retention in HIV Prevention and Treatment Clinical Services Among Female Sex Workers Enrolled in a Sex Workers' Outreach Program (SWOP) in Nairobi, Kenya. AIDS Behav. 2022 Sep;26(9):2969-2980. doi: 10.1007/s10461-022-03654-0. Epub 2022 Mar 17. PMID: 35299260; PMCID: PMC10256564.