Cost-Effectiveness of Oral Pre-Exposure Prophylaxis and Expanded Antiretroviral Therapy for Preventing HIV Infections in the Presence of Drug Resistance: A Mathematical Modelling Study
Background: Oral pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) can effectively prevent HIV infections among men who have sex with men (MSM), but the emergence and transmission of HIV drug-resistance (HIVDR) may compromise their benefits. The costs and benefits of expanding PrEP and ART coverage in the presence of HIVDR in China remain unknown. Methods: We developed a comprehensive dynamic transmission model incorporating the transmitted (TDR) and acquired (ADR) HIV drug resistance. The model was calibrated by the HIV surveillance data from 2009 to 2019 among MSM in Jiangsu Province, China and validated by the dynamic prevalence of ADR and TDR. We aimed to investigate the impact of eight intervention scenarios (no PrEP, 20%, 50% or 80% of PrEP, without (77% coverage) or with (90% coverage) expanded ART) on the HIV epidemic trend and cost-effectiveness of PrEP over the next 30 years. Findings: 20% or 50% PrEP + 90% ART would be cost-effective, with an incremental cost-effectiveness ratio (ICER) of 25,417 (95% confidence interval [CI]: 12,390–38,445) or 47,243 (23,756–70,729), and would yield 154,949 (89,662–220,237) or 179,456 (102,570–256,342) incremental quality-adjusted life-years (QALYs) over the next 30 years. No PrEP + 90% ART would yield 125,211 (73,448–176,974) incremental QALYs and be cost-saving. However, 20–80% PrEP + 77% ART and 80% PrEP + 90% ART with ICER of $77,862–98,338 and $63,332, respectively, and is not cost-effective. A reduction of 64% in the annual cost of oral PrEP would make it highly cost-effective for 50% PrEP + 90% ART. Interpretation: 20% or 50% PrEP + 90% ART is cost-effective for HIV control in the presence of HIVDR. Expanded ART alone may be the optimal policy under the current limited budgets. Funding Information: National Natural Science Foundation of China, the National S&T Major Project Foundation of China. Declaration of Interests: All authors declare that they have no competing interests. Ethics Approval Statement: The work was approved by the ethical committee of Nanjing Medical University (“F”, “CH”, “Nanjing Med U”, “FWA00001501”, “NANJING”, 11/21/2004), and an IRB (Institutional Review Board) approval was given prior to this study. I have read and have abided by the statement of ethical standards for manuscripts submitted to International Journal of Infectious Diseases