Where to Deploy Pre-Exposure Prophylaxis (PrEP) in Sub-Saharan Africa?

September 2013 - Combination Prevention

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Verguet, S., Stalcup, M., and Walsh, J.A. Sexually Transmitted Infections (August 2013), E-publication ahead of print.

The authors used a deterministic epidemiologic model to assess the impact and cost-effectiveness of implementing a pre-exposure prophylaxis (PrEP) intervention from 2013 to 2017 for the general adult population in 42 countries in sub-Saharan Africa. The findings suggest a large impact on HIV, with maximum impact and cost-effectiveness in general adult populations with low levels of male circumcision (MC) and high HIV prevalence. Southern African countries would benefit most from PrEP, whereas West and Central African countries would benefit least. PrEP would be most cost-effective in generalized epidemics; but in other contexts, PrEP should be prioritized for key populations. Over five years, PrEP could prevent 390,000 HIV infections, 53,000 deaths, and 5,400,000 disability-adjusted life years (DALYs) if implemented at 10 percent coverage in the region. The greatest impact would be in South Africa; the smallest in Djibouti (94,0000 and 200 infections averted, respectively). Overall, the cost-effectiveness of PrEP was U.S. $5,800/DALY. PrEP was very cost-effective in South Africa ($1,100/DALY) compared to in the Democratic Republic of the Congo ($18,500/DALY). In high-risk populations, PrEP would substantially increase protection (557,000 infections averted at $3,800/DALY). The authors provided a model that can be adapted to help make health policy decisions about PrEP interventions; decisions should align with country economic indicators and epidemiologic contexts. PrEP would likely be most cost-effective as a targeted intervention within a combination of HIV prevention strategies.

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