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The cost-effectiveness of HIV pre-exposure prophylaxis in high-risk men who have sex with men and transgendered women in Brazil Paula M. Luz, Ben Osher,

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Presentation on theme: "The cost-effectiveness of HIV pre-exposure prophylaxis in high-risk men who have sex with men and transgendered women in Brazil Paula M. Luz, Ben Osher,"— Presentation transcript:

1 The cost-effectiveness of HIV pre-exposure prophylaxis in high-risk men who have sex with men and transgendered women in Brazil Paula M. Luz, Ben Osher, Beatriz Grinsztejn, Rachel L. MacLean, Elena Losina, Claudio J. Struchiner, Robert A. Parker, Kenneth A. Freedberg, Fabio Mesquita, Rochelle P. Walensky, Valdilea G. Veloso, A. David Paltiel Supported by: The National Council of Technological and Scientific Development (CNPq) and the Research Funding Agency of the State of Rio de Janeiro (FAPERJ) (Brazil), The National Institute of Allergy and Infectious Diseases (R01 AI058736) (USA)

2 I have no financial relationships with commercial entities to disclose.

3 Background PrEP efficacy for prevention of sexually acquired HIV infection among MSM ranges from 44-86% (iPrEX, IPERGAY, PROUD) 2016 meta-analysis: pooled PrEP efficacy of 70% for high-risk populations with high adherence (Fonner et al, AIDS 2016) WHO guidelines recommend PrEP for high-risk populations

4 Background In Brazil, MSM/TGW are at particularly high risk of HIV infection: Prevalence: TGW: 33% (Baral et al, Lancet ID 2013) MSM: 23% (Kerr et al, AIDS 2013) Incidence: 6/100PY (Beyrer et al, AIDS 2013) Reported AIDS cases increased by 40% over 10 years among young MSM (BMoH 2015)

5 Objective To assess the clinical impact, costs, and cost-effectiveness of PrEP compared to no PrEP among high-risk MSM/TGW in Brazil

6 Methods CEPAC-I Brazil Model
Cost-effectiveness of Preventing AIDS Complications (CEPAC)-International Model Microsimulation model of HIV infection HIV-negative are subject to HIV incidence rates + testing HIV-infected disease progression + treatment Uses clinical/cost data from Brazil Cost: Department of STIs, AIDS and Viral Hepatitis (BMoH) High-risk population characteristics and uptake from PrEP Brasil, a multicenter, open-label demonstration project assessing PrEP for high-risk MSM and TGW in the Brazilian public health system in Rio de Janeiro and São Paulo

7 Methods Strategies examined in the model
No PrEP Monthly risk of HIV infection HIV testing was per observed testing rates Upon infection, treatment according to Brazilian Guidelines (ART free-of-charge to all HIV-infected) PrEP Tenofovir-FTC based PrEP Lifetime Reduces infection risk by 86% HIV testing every 4 months Creatinine annually

8 Methods Model input parameters
Variable Base case value (range) Reference Age, mean [SD] (years) 31.4 [8.4] PrEP Brasil Acute CD4 count, mean [SD] (cells/μl) 559 [236] Grant 2015 HIV incidence rate ≤40 years (/100PY) 4.3 iPrEX >40 years (/100PY) 1.0 PrEP Efficacy 86% (31%-100%) PROUD Drug cost ($, monthly) 12.5 ( ) BMoH* ART, 1st line Cost ($, monthly) 10 (6-10) * Department of STIs, AIDS and Viral Hepatitis, Ministry of Health, Brazil

9 Methods CEPAC-I Brazil Model
Model outcomes: Clinical: Infections Deaths Life-expectancy Economic: Per-person lifetime costs, from perspective of the National Health System Incremental cost-effectiveness ratios (ICER, 2015$/YLS) Per international guidelines, we defined a strategy as “cost-effective” if ICER < GDP per capita ($11,730)

10 Results Outcome No PrEP PrEP
HIV infection risk (infections/1000 high-risk men) 5-year 162 25 Lifetime 506 100 HIV attributable mortality (deaths/1000 high-risk men) 13 1 223 20

11 Results Outcome No PrEP PrEP
HIV infection risk (infections/1000 high-risk men) 5-year 162 25 Lifetime 506 100 HIV attributable mortality (deaths/1000 high-risk men) 13 1 223 20 80%

12 Results Outcome No PrEP PrEP
HIV infection risk (infections/1000 high-risk men) 5-year 162 25 Lifetime 506 100 HIV attributable mortality (deaths/1000 high-risk men) 13 1 223 20 91%

13 Results Per-person life expectancy* (years) Per-person lifetime cost*
(2014 USD) ICER* ($/YLS) No PrEP 20.7 $4,090 -- PrEP 23.0 $5,130 $460 2.3 years $1,040 * Discounted at 3%

14 Results Per-person life expectancy* (years) Per-person lifetime cost*
(2014 USD) ICER* ($/YLS) No PrEP 20.7 $4,090 -- PrEP 23.0 $5,130 $460 2.3 years $1,040 * Discounted at 3% $460 is <4% of Brazil’s GDP per capita  PrEP is highly cost-effective

15 Results Per-person life expectancy* (years) Per-person lifetime cost*
(2014 USD) ICER* ($/YLS) No PrEP 20.7 $4,090 -- PrEP 23.0 $5,130 $460 2.3 years $1,040 * Discounted at 3% $460 is <4% of Brazil’s GDP per capita  PrEP is highly cost-effective PrEP remained highly cost-effective when varying key parameters

16 Sensitivity analysis Incidence and efficacy
PrEP drug cost =$12.5/month ($150/year) Cost-saving ICER < 1x GDP ICER > 1x GDP 0.4 #### 0.9 8794 8346 8053 7967 7714 7386 7138 6821 6433 6200 5863 5661 5315 5089 4906 4586 1.3 6208 5953 5603 5420 5313 5047 4756 4498 4257 3973 3734 3516 3265 3047 2842 2640 1.7 4990 4656 4389 4236 4149 3845 3619 3383 3142 2888 2675 2447 2235 2029 1822 1655 2.1 4226 3950 3690 3549 3448 3193 2961 2719 2512 2283 2058 1842 1627 1436 1237 1076 2.6 3758 3507 3261 3109 3005 2771 2530 2303 2082 1855 1433 1239 1035 846 687 3.0 3409 3163 2918 2775 2671 2451 2212 1994 1782 1564 1357 1150 951 751 555 403 3.4 3172 2923 2702 2553 2461 2224 2016 1785 1577 1362 1161 953 748 553 358 204 3.8 2973 2741 2511 2378 2293 2056 1843 1628 1414 1201 986 790 588 387 192 39 4.3 2825 2610 2380 2248 2167 1933 1714 1503 1289 1077 869 663 463 265 65.8 -88.6 4.7 2703 2504 2269 2141 2044 1839 1613 1403 1191 977 769 563 363 159 -40.3 -197 5.1 2626 2401 2184 2051 1965 1748 1537 1319 1109 903 689 490 282 80.5 -123 -283 5.6 2544 2337 2125 1995 1902 1680 1474 1261 1050 836 631 420 209 7.87 -199 -360 6.0 2503 2288 2067 1940 1853 1644 1434 1220 1002 791 579 371 160 -50.5 -259 -423 6.4 2450 2243 2020 1901 1819 1598 1389 1176 960 750 537 321 110 -103 -313 -479 6.8 2409 2195 1988 1854 1776 1563 1353 1148 932 720 501 291 80.4 -140 -353 -523 7.3 2356 2153 1946 1831 1746 1531 1328 1112 690 472 256 37.8 -176 -394 -567 7.7 2117 1922 1804 1506 1301 1091 878 661 441 224 7.22 -215 -434 -609 8.1 2313 2112 1908 1783 1705 1500 1285 1074 855 645 426 206 -9.32 -236 -460 -639 8.6 2291 2098 1898 1772 1695 1484 1282 1066 638 414 195 -31.2 -254 -484 -667 31 36 41 44 46 51 56 61 66 71 76 81 86 91 96 100 X Incidence rate/100PY PrEP efficacy (%)

17 Sensitivity analysis Two-way
PrEP drug cost =$12.5/month ($150/year) Cost-saving ICER < 1x GDP ICER > 1x GDP 0.4 #### 0.9 8794 8346 8053 7967 7714 7386 7138 6821 6433 6200 5863 5661 5315 5089 4906 4586 1.3 6208 5953 5603 5420 5313 5047 4756 4498 4257 3973 3734 3516 3265 3047 2842 2640 1.7 4990 4656 4389 4236 4149 3845 3619 3383 3142 2888 2675 2447 2235 2029 1822 1655 2.1 4226 3950 3690 3549 3448 3193 2961 2719 2512 2283 2058 1842 1627 1436 1237 1076 2.6 3758 3507 3261 3109 3005 2771 2530 2303 2082 1855 1433 1239 1035 846 687 3.0 3409 3163 2918 2775 2671 2451 2212 1994 1782 1564 1357 1150 951 751 555 403 3.4 3172 2923 2702 2553 2461 2224 2016 1785 1577 1362 1161 953 748 553 358 204 3.8 2973 2741 2511 2378 2293 2056 1843 1628 1414 1201 986 790 588 387 192 39 4.3 2825 2610 2380 2248 2167 1933 1714 1503 1289 1077 869 663 463 265 65.8 -88.6 4.7 2703 2504 2269 2141 2044 1839 1613 1403 1191 977 769 563 363 159 -40.3 -197 5.1 2626 2401 2184 2051 1965 1748 1537 1319 1109 903 689 490 282 80.5 -123 -283 5.6 2544 2337 2125 1995 1902 1680 1474 1261 1050 836 631 420 209 7.87 -199 -360 6.0 2503 2288 2067 1940 1853 1644 1434 1220 1002 791 579 371 160 -50.5 -259 -423 6.4 2450 2243 2020 1901 1819 1598 1389 1176 960 750 537 321 110 -103 -313 -479 6.8 2409 2195 1988 1854 1776 1563 1353 1148 932 720 501 291 80.4 -140 -353 -523 7.3 2356 2153 1946 1831 1746 1531 1328 1112 690 472 256 37.8 -176 -394 -567 7.7 2117 1922 1804 1506 1301 1091 878 661 441 224 7.22 -215 -434 -609 8.1 2313 2112 1908 1783 1705 1500 1285 1074 855 645 426 206 -9.32 -236 -460 -639 8.6 2291 2098 1898 1772 1695 1484 1282 1066 638 414 195 -31.2 -254 -484 -667 31 36 41 44 46 51 56 61 66 71 76 81 86 91 96 100 X Incidence rate/100PY PrEP efficacy (%)

18 Sensitivity analysis Two-way
PrEP drug cost =$12.5/month ($150/year) Cost-saving ICER < 1x GDP ICER > 1x GDP 0.4 #### 0.9 8794 8346 8053 7967 7714 7386 7138 6821 6433 6200 5863 5661 5315 5089 4906 4586 1.3 6208 5953 5603 5420 5313 5047 4756 4498 4257 3973 3734 3516 3265 3047 2842 2640 1.7 4990 4656 4389 4236 4149 3845 3619 3383 3142 2888 2675 2447 2235 2029 1822 1655 2.1 4226 3950 3690 3549 3448 3193 2961 2719 2512 2283 2058 1842 1627 1436 1237 1076 2.6 3758 3507 3261 3109 3005 2771 2530 2303 2082 1855 1433 1239 1035 846 687 3.0 3409 3163 2918 2775 2671 2451 2212 1994 1782 1564 1357 1150 951 751 555 403 3.4 3172 2923 2702 2553 2461 2224 2016 1785 1577 1362 1161 953 748 553 358 204 3.8 2973 2741 2511 2378 2293 2056 1843 1628 1414 1201 986 790 588 387 192 39 4.3 2825 2610 2380 2248 2167 1933 1714 1503 1289 1077 869 663 463 265 65.8 -88.6 4.7 2703 2504 2269 2141 2044 1839 1613 1403 1191 977 769 563 363 159 -40.3 -197 5.1 2626 2401 2184 2051 1965 1748 1537 1319 1109 903 689 490 282 80.5 -123 -283 5.6 2544 2337 2125 1995 1902 1680 1474 1261 1050 836 631 420 209 7.87 -199 -360 6.0 2503 2288 2067 1940 1853 1644 1434 1220 1002 791 579 371 160 -50.5 -259 -423 6.4 2450 2243 2020 1901 1819 1598 1389 1176 960 750 537 321 110 -103 -313 -479 6.8 2409 2195 1988 1854 1776 1563 1353 1148 932 720 501 291 80.4 -140 -353 -523 7.3 2356 2153 1946 1831 1746 1531 1328 1112 690 472 256 37.8 -176 -394 -567 7.7 2117 1922 1804 1506 1301 1091 878 661 441 224 7.22 -215 -434 -609 8.1 2313 2112 1908 1783 1705 1500 1285 1074 855 645 426 206 -9.32 -236 -460 -639 8.6 2291 2098 1898 1772 1695 1484 1282 1066 638 414 195 -31.2 -254 -484 -667 31 36 41 44 46 51 56 61 66 71 76 81 86 91 96 100 X Incidence rate/100PY PrEP efficacy (%)

19 Sensitivity analysis Two-way
2x PrEP drug cost = $25/month ($300/year) Cost-saving ICER < 1x GDP ICER > 1x GDP 0.4 #### 0.9 1.3 9998 9790 9488 9109 8847 8445 8190 7825 7551 7325 7016 6783 6520 1.7 8499 8177 7864 7668 7479 7202 6935 6674 6366 6095 5859 5570 5336 5111 4863 4650 2.1 7072 6757 6475 6338 6191 5924 5648 5399 5124 4884 4648 4416 4183 3946 3724 3546 2.6 6144 5874 5593 5442 5324 5066 4819 4575 4337 4097 3855 3642 3413 3192 2986 2813 3.0 5446 5182 4955 4785 4696 4468 4207 3969 3738 3520 3280 3065 2858 2643 2445 2277 3.4 4972 4719 4483 4327 4248 3999 3764 3537 3331 3097 2879 2672 2459 2253 2059 1891 3.8 4574 4353 4105 3970 3883 3421 3202 2978 2772 2560 2345 2138 1940 1740 1578 4.3 4298 4050 3835 3700 3599 3375 3153 2935 2730 2513 2308 2100 1897 1695 1492 1335 4.7 4040 3820 3598 3464 3376 2937 2724 2517 2090 1893 1683 1289 1132 5.1 3838 3612 3403 3288 3181 2766 2547 2344 2134 1930 1723 1523 1322 1122 965 5.6 3689 3449 3256 3115 3037 2825 2631 2411 2207 1995 1798 1588 1388 1182 980 823 6.0 3552 3337 3124 2998 2920 2719 2499 2298 2089 1887 1680 1476 1271 1074 868 706 6.4 3434 3234 3028 2908 2823 2611 2408 2206 1992 1788 1586 1382 1174 968 765 602 6.8 3328 3118 2918 2805 2722 2522 2317 2114 1910 1707 1500 1294 1087 882 676 512 7.3 3235 3029 2829 2710 2637 2438 2240 2039 1833 1629 1424 1213 1008 800 596 429 7.7 3152 2963 2771 2646 2572 2379 2170 1967 1766 1567 1361 1148 947 734 524 356 8.1 3087 2903 2702 2591 2510 2323 2116 1919 1716 1510 1300 1096 887 464 294 8.6 3042 2852 2666 2544 2471 2276 2078 1874 1677 1472 1265 1056 841 629 415 241 31 36 41 44 46 51 56 61 66 71 76 81 86 91 96 100 X Incidence rate/100PY PrEP efficacy (%)

20 Sensitivity analysis Two-way
2x PrEP drug cost = $25/month ($300/year) Cost-saving ICER < 1x GDP ICER > 1x GDP 0.4 #### 0.9 1.3 9998 9790 9488 9109 8847 8445 8190 7825 7551 7325 7016 6783 6520 1.7 8499 8177 7864 7668 7479 7202 6935 6674 6366 6095 5859 5570 5336 5111 4863 4650 2.1 7072 6757 6475 6338 6191 5924 5648 5399 5124 4884 4648 4416 4183 3946 3724 3546 2.6 6144 5874 5593 5442 5324 5066 4819 4575 4337 4097 3855 3642 3413 3192 2986 2813 3.0 5446 5182 4955 4785 4696 4468 4207 3969 3738 3520 3280 3065 2858 2643 2445 2277 3.4 4972 4719 4483 4327 4248 3999 3764 3537 3331 3097 2879 2672 2459 2253 2059 1891 3.8 4574 4353 4105 3970 3883 3421 3202 2978 2772 2560 2345 2138 1940 1740 1578 4.3 4298 4050 3835 3700 3599 3375 3153 2935 2730 2513 2308 2100 1897 1695 1492 1335 4.7 4040 3820 3598 3464 3376 2937 2724 2517 2090 1893 1683 1289 1132 5.1 3838 3612 3403 3288 3181 2766 2547 2344 2134 1930 1723 1523 1322 1122 965 5.6 3689 3449 3256 3115 3037 2825 2631 2411 2207 1995 1798 1588 1388 1182 980 823 6.0 3552 3337 3124 2998 2920 2719 2499 2298 2089 1887 1680 1476 1271 1074 868 706 6.4 3434 3234 3028 2908 2823 2611 2408 2206 1992 1788 1586 1382 1174 968 765 602 6.8 3328 3118 2918 2805 2722 2522 2317 2114 1910 1707 1500 1294 1087 882 676 512 7.3 3235 3029 2829 2710 2637 2438 2240 2039 1833 1629 1424 1213 1008 800 596 429 7.7 3152 2963 2771 2646 2572 2379 2170 1967 1766 1567 1361 1148 947 734 524 356 8.1 3087 2903 2702 2591 2510 2323 2116 1919 1716 1510 1300 1096 887 464 294 8.6 3042 2852 2666 2544 2471 2276 2078 1874 1677 1472 1265 1056 841 629 415 241 31 36 41 44 46 51 56 61 66 71 76 81 86 91 96 100 X Incidence rate/100PY PrEP efficacy (%)

21 Sensitivity analysis Two-way
2x PrEP drug cost = $25/month ($300/year) Cost-saving ICER < 1x GDP ICER > 1x GDP 0.4 #### 0.9 1.3 9998 9790 9488 9109 8847 8445 8190 7825 7551 7325 7016 6783 6520 1.7 8499 8177 7864 7668 7479 7202 6935 6674 6366 6095 5859 5570 5336 5111 4863 4650 2.1 7072 6757 6475 6338 6191 5924 5648 5399 5124 4884 4648 4416 4183 3946 3724 3546 2.6 6144 5874 5593 5442 5324 5066 4819 4575 4337 4097 3855 3642 3413 3192 2986 2813 3.0 5446 5182 4955 4785 4696 4468 4207 3969 3738 3520 3280 3065 2858 2643 2445 2277 3.4 4972 4719 4483 4327 4248 3999 3764 3537 3331 3097 2879 2672 2459 2253 2059 1891 3.8 4574 4353 4105 3970 3883 3421 3202 2978 2772 2560 2345 2138 1940 1740 1578 4.3 4298 4050 3835 3700 3599 3375 3153 2935 2730 2513 2308 2100 1897 1695 1492 1335 4.7 4040 3820 3598 3464 3376 2937 2724 2517 2090 1893 1683 1289 1132 5.1 3838 3612 3403 3288 3181 2766 2547 2344 2134 1930 1723 1523 1322 1122 965 5.6 3689 3449 3256 3115 3037 2825 2631 2411 2207 1995 1798 1588 1388 1182 980 823 6.0 3552 3337 3124 2998 2920 2719 2499 2298 2089 1887 1680 1476 1271 1074 868 706 6.4 3434 3234 3028 2908 2823 2611 2408 2206 1992 1788 1586 1382 1174 968 765 602 6.8 3328 3118 2918 2805 2722 2522 2317 2114 1910 1707 1500 1294 1087 882 676 512 7.3 3235 3029 2829 2710 2637 2438 2240 2039 1833 1629 1424 1213 1008 800 596 429 7.7 3152 2963 2771 2646 2572 2379 2170 1967 1766 1567 1361 1148 947 734 524 356 8.1 3087 2903 2702 2591 2510 2323 2116 1919 1716 1510 1300 1096 887 464 294 8.6 3042 2852 2666 2544 2471 2276 2078 1874 1677 1472 1265 1056 841 629 415 241 31 36 41 44 46 51 56 61 66 71 76 81 86 91 96 100 X Incidence rate/100PY PrEP efficacy (%)

22 Limitations PrEP efficacy Cost assumptions are best estimates
Highly dependent on adherence At lower efficacy, PrEP is cost-effective Cost assumptions are best estimates PrEP drug costs up for negotiation

23 Conclusions Compared to No PrEP, PrEP is cost-effective in Brazil with an ICER of $460/YLS, which is well below Brazil’s GDP per capita PrEP’s cost-effectiveness is robust to parameter variation including substantially lower PrEP efficacy

24 Thank you for your attention.

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