Open AccessDapivirine vaginal ring for HIV prevention: modelling health outcomes, drug resistance and cost‐effectiveness
Author(s) -
Glaubius Robert,
Ding Yajun,
Penrose Kerri J,
Hood Greg,
Engquist Erik,
Mellors John W,
Parikh Urvi M,
Abbas Ume L
Publication year - 2019
Publication title -
journal of the international aids society
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 2.724
H-Index - 62
ISSN - 1758-2652
DOI - 10.1002/jia2.25282
Subject(s) - medicine , vaginal ring , pre exposure prophylaxis , cost effectiveness , incidence (geometry) , hiv drug resistance , gynecology , obstetrics , demography , human immunodeficiency virus (hiv) , environmental health , men who have sex with men , family medicine , antiretroviral therapy , population , viral load , family planning , risk analysis (engineering) , physics , syphilis , sociology , optics , research methodology
A vaginal ring containing dapivirine is effective for HIV prevention as pre‐exposure prophylaxis (Pr EP ). We evaluated the potential epidemiological impact and cost‐effectiveness of dapivirine vaginal ring Pr EP among 22‐ to 45‐year‐old women in KwaZulu‐Natal, South Africa. Methods Using mathematical modelling, we studied dapivirine vaginal ring Pr EP implementation, either unprioritized, or prioritized based on HIV incidence (≥3% per year), age (22 to 29 years) or female sex worker status, alongside the implementation of voluntary medical male circumcision and antiretroviral therapy scaled‐up to UNAIDS Fast‐Track targets. Outcomes over the intervention (2019 to 2030) and lifetime horizons included cumulative HIV infect ions, life‐years lived, costs and cost‐effectiveness. We assessed the incremental cost‐effectiveness ratios against the revealed willingness to pay ($500) and the standard (2017 per capita gross domestic product; $6161) cost‐effectiveness thresholds for South Africa. Results Compared to a reference scenario without Pr EP , implementation of dapivirine vaginal ring Pr EP , assuming 56% effectiveness and covering 50% of 22 to 29‐year‐old or high‐incidence women, prevented 10% or 11% of infections by 2030 respectively. Equivalent, unprioritized coverage (30%) prevented fewer infections (7%), whereas 50% coverage of female sex workers had the least impact (4%). Drug resistance attributable to Pr EP was modest (2% to 4% of people living with drug‐resistant HIV ). Over the lifetime horizon, dapivirine Pr EP implementation among female sex workers was cost‐saving, whereas incidence‐based Pr EP cost $1898 per life‐year gained, relative to Pr EP among female sex workers and $989 versus the reference scenario. In a scenario of 37% Pr EP effectiveness, Pr EP had less impact, but prioritization to female sex workers remained cost‐saving. In uncertainty analysis, female sex worker Pr EP was consistently cost‐saving; and over the lifetime horizon, Pr EP cost less than $6161 per life‐year gained in over 99% of simulations, whereas incidence‐ and age‐based Pr EP cost below $500 per life‐year gained in 61% and 49% of simulations respectively. Pr EP adherence and efficacy, and the effectiveness of antiretroviral therapy for HIV prevention, were the principal drivers of uncertainty in the cost‐effectiveness of Pr EP . Conclusions Dapivirine vaginal ring Pr EP would be cost‐saving in KwaZulu‐Natal if prioritized to female sex workers. Pr EP 's impact on HIV prevention would be increased, with potential affordability, if prioritized to women by age or incidence.