The impact, cost and cost-effectiveness of oral pre-exposure prophylaxis in sub-Saharan Africa: a scoping review of modelling contributions and way forward
File(s)
Published version
Supporting information
Author(s)
Case, Kelsey
Gomez, Gabriela
Hallett, Timothy
Type
Journal Article
Abstract
Introduction: Oral pre-exposure prophylaxis (PrEP) is a new form of HIV prevention being considered for inclusion in national prevention portfolios. Many mathematical modelling studies have been undertaken that speak to the impact, cost and cost-effectiveness of PrEP programmes. We assess the available evidence from mathematical modelling studies to inform programme planning and policy decision making for PrEP and further research directions.
Methods: We conducted a scoping review of the published modelling literature. Articles published in English which modelled oral PrEP in sub-Saharan Africa, or non-specific settings with relevance to generalised HIV epidemic settings, were included. Data were extracted for the strategies of PrEP use modelled, and the impact, cost and cost-effectiveness of PrEP for each strategy. We define an algorithm to assess the quality and relevance of studies included, summarise the available evidence and identify the current gaps in modelling. Recommendations are generated for future modelling applications and data collection.
Results and discussion: We reviewed 1,924 abstracts and included 44 studies spanning 2007 to 2017. Modelling has reported that PrEP can be a cost-effective addition to HIV prevention portfolios for some use cases, but also that it would not be cost-effective to fund PrEP before other prevention intervention are expanded. However, our assessment of the quality of the modelling indicates cost-effectiveness analyses failed to comply with standards of reporting for economic evaluations and the assessment of relevance highlighted that both key parameters and scenarios are now outdated. Current evidence gaps include modelling to inform service development using updated programmatic information and ex post modelling to evaluate and inform efficient deployment of resources in support of PrEP, especially among key populations, using direct evidence of cost, adherence and uptake patterns.
Conclusions: Updated modelling which more appropriately captures PrEP programme delivery, uses current intervention scenarios, and is parameterised with data from demonstration and implementation projects is needed in support of more conclusive findings and actionable recommendations for programmes and policy. Future analyses should address these issues, aligning with countries to support the needs of programme planners and decision makers for models to more directly inform programme planning and policy.
Methods: We conducted a scoping review of the published modelling literature. Articles published in English which modelled oral PrEP in sub-Saharan Africa, or non-specific settings with relevance to generalised HIV epidemic settings, were included. Data were extracted for the strategies of PrEP use modelled, and the impact, cost and cost-effectiveness of PrEP for each strategy. We define an algorithm to assess the quality and relevance of studies included, summarise the available evidence and identify the current gaps in modelling. Recommendations are generated for future modelling applications and data collection.
Results and discussion: We reviewed 1,924 abstracts and included 44 studies spanning 2007 to 2017. Modelling has reported that PrEP can be a cost-effective addition to HIV prevention portfolios for some use cases, but also that it would not be cost-effective to fund PrEP before other prevention intervention are expanded. However, our assessment of the quality of the modelling indicates cost-effectiveness analyses failed to comply with standards of reporting for economic evaluations and the assessment of relevance highlighted that both key parameters and scenarios are now outdated. Current evidence gaps include modelling to inform service development using updated programmatic information and ex post modelling to evaluate and inform efficient deployment of resources in support of PrEP, especially among key populations, using direct evidence of cost, adherence and uptake patterns.
Conclusions: Updated modelling which more appropriately captures PrEP programme delivery, uses current intervention scenarios, and is parameterised with data from demonstration and implementation projects is needed in support of more conclusive findings and actionable recommendations for programmes and policy. Future analyses should address these issues, aligning with countries to support the needs of programme planners and decision makers for models to more directly inform programme planning and policy.
Date Issued
2019-09-01
Date Acceptance
2019-08-06
Citation
Journal of the International AIDS Society, 2019, 22 (9)
ISSN
1758-2652
Publisher
International AIDS Society
Journal / Book Title
Journal of the International AIDS Society
Volume
22
Issue
9
Copyright Statement
© 2019 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
Sponsor
Bill & Melinda Gates Foundation
Grant Number
OPP1084364
Subjects
Science & Technology
Life Sciences & Biomedicine
Immunology
Infectious Diseases
PrEP
modelling
combination prevention
cost-effectiveness
sub-Saharan Africa
COMBINATION HIV PREVENTION
DRUG-RESISTANCE
ANTIRETROVIRAL TREATMENT
SERODISCORDANT COUPLES
LIMITED IMPACT
SOUTH-AFRICA
HIGH-RISK
PREP
WOMEN
SEX
PrEP
combination prevention
cost-effectiveness
modelling
sub-Saharan Africa
1199 Other Medical and Health Sciences
Publication Status
Published
Article Number
ARTN e25390
Date Publish Online
2019-09-19