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HIV PrEP currently too pricey to justify use in people who inject drugs

HIV preexposure prophylaxis (PrEP) has individual and population health benefits, but the intervention is currently too expensive to implement in people who inject drugs. The findings are published in Annals of Internal Medicine.

Injection drug users make up only about 1 percent of the U.S. adult population but account for approximately 10 percent of all new HIV infections. Daily oral PrEP has been proven effective for reducing HIV infection in injection drug users and the CDC has recommended PrEP as one prevention option for adult injection drug users at substantial risk of HIV acquisition. However, the cost and health benefits of implementing a national program are unclear.

Researchers developed a computer model of the U.S. HIV population to evaluate the public health benefit and cost of a national PrEP program for injection drug users. The model considered PrEP alone, PrEP with frequent screening, and PrEP with frequent screening and prompt treatment with antiretroviral therapy (ART) for those who become infected.

The model suggested that over 20 years, enrolling a quarter of HIV uninfected injection drug users in a PrEP + screening + ART program would be the optimal approach for reducing HIV infection. However, at current drug prices this approach would cost the U.S. an additional $44 billion, which is equivalent to annually spending 10 percent of the current federal budget for domestic HIV/AIDS on PrEP for people who inject drugs. In addition, the intervention would prevent about 21,500 new infections over 20 years, making it cost-prohibitive in both absolute terms and in cost per cost per quality-adjusted life years (QALY) gained.

The author of an accompanying editorial says that even at lower drug prices, HIV PrEP for injection drug users may not be an efficient use of HIV prevention resources. HIV is no longer deadly, but injection drug users face a high risk for overdose and death. Investments in access to naloxone therapy, medical insurance and detoxification programs, opioid agonist therapy, and needle exchange could possibly prevent HIV infections better than PrEP and also provide an immediate life-saving benefit.

Article: Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United States, Cora L. Bernard, MS; Margaret L. Brandeau, PhD; Keith Humphreys, PhD; Eran Bendavid, MD, MS; Mark Holodniy, MD; Christopher Weyant, MS; Douglas K. Owens, MD, MS; and Jeremy D. Goldhaber-Fiebert, PhD, Annals of Internal Medicine, doi:10.7326/M15-2634, published online 26 April 2016.

Editorial: Investing in People Who Inject Drugs: A PrEPonderance of Opportunities, Rochelle P. Walensky, MD, MPH, Annals of Internal Medicine, doi:10.7326/M16-0788, published online 26 April 2016.