The need for HIV prevention is higher than ever as HIV-incidence remains a staggering 2.1 million new infections every year, globally. While the successful scale-up of antiretroviral therapy lead to a substantial decline in HIV mortality, LSTM’s Professors Niessen and Jaffar signal that the limited effectiveness of HIV prevention leads to ever increasing numbers of people living with HIV worldwide. This causes an enormous demand for accessible and affordable treatment, challenging health systems and universal health coverage attempts.
In a comment in the journal Lancet Infectious Diseases, they argue that the body of evidence on effective HIV prevention options for world-wide prevention has increased. This is in response to the findings of an Erasmus Medical Centre study on the attractiveness of pre-exposure prophylaxis (PrEP) with tenofovir and emtricitabine prevents HIV infections among highly sexually active men who have sex with men, published in the same edition. It is known that PrEP with tenofovir and emtricitabine prevents HIV infections among highly sexually active groups either given regularly or intermittently on demand. However, PrEP is only recently approved by the EMA, although not yet for reimbursement in European countries, nor in most other settings.
The premise of the paper by the team at Erasmus is that the PrEP is affordable by their economic standards as their study finds that PrEP is more cost-effective - in theory - when used on-demand at €2000 (IQR 1300–3000) per QALY gained as compared with daily treatment at €11 000 (IQR 9400–14 100) per QALY gained as compared with daily treatment, at €14,300 (IQR €11,300-€20,900) at an 80% efficacy level. They find that substantial decrease in drug prices could actually lead to net savings in local health care costs.
LSTM’s Professor Jaffar said: “PrEP is one of the attractive HIV prevention options in a variety of global settings where HIV incidence remains high. Of course, following the promising findings by Erasmus, more specific empirical evaluation and implementation research is needed across the globe to assess effectiveness and efficiency of HIV prevention. We know now that large-scale implementation of effective prevention strategies will be necessary to be able to measure population impact, especially in high-risk groups.”
In a reply to LSTM’s comments on the paper, leading researcher Dr. David van de Vijver at Erasmus Medical Centre says: “Once the patents on the PrEP drugs tenofovir and emtricitabine expire, other manufacturers will also be allowed to make the drugs. We expect that the drugs will then become cheaper, which means that administering PrEP to the high risk groups could even become cost saving.”
LSTM’s Professor Niessen added: “This would reduce the already huge burden on the health systems and households without advanced health services and health financing mechanism. There are still limited insights on why prevention works in some populations and why it fails in other specific subgroups. Real-life cost-effectiveness of HIV-prevention strategies remains very limited across the world, challenging policy makers in making decisions and public and private financing strategies.”
Both professors Jaffar and Niessen argue that implementation of wide-scale HIV prevention will need a continuation of strengthening demand and compliance, increased coverage, and affordable drugs at both the household and health system levels, everywhere.