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Abstract

Background

Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy for men-who-have-sex-with-men (MSM). The high cost of PrEP has until recently been a primary barrier to its use. In 2017, generic PrEP became available, reducing the costs by 90%.

Aim

Our objective was to assess cost-effectiveness and costs of introducing PrEP in Germany.

Methods

We calibrated a deterministic mathematical model to the human immunodeficiency virus (HIV) epidemic among MSM in Germany. PrEP was targeted to 30% of high-risk MSM. It was assumed that PrEP reduces the risk of HIV infection by 85%. Costs were calculated from a healthcare payer perspective using a 40-year time horizon starting in 2018.

Results

PrEP can avert 21,000 infections (interquartile range (IQR): 16,000–27,000) in the short run (after 2 years scale-up and 10 years full implementation). HIV care is predicted to cost EUR 36.2 billion (IQR: 32.4–40.4 billion) over the coming 40 years. PrEP can increase costs by at most EUR 150 million within the first decade after introduction. Ten years after introduction, PrEP can become cost-saving, accumulating to savings of HIV-related costs of EUR 5.1 billion (IQR: 3.5–6.9 billion) after 40 years. In a sensitivity analysis, PrEP remained cost-saving even at a 70% price reduction of antiretroviral drug treatment and a lower effectiveness of PrEP.

Conclusion

Introduction of PrEP in Germany is predicted to result in substantial health benefits because of reductions in HIV infections. Short-term financial investments in providing PrEP will result in substantial cost-savings in the long term.

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2019-02-14
2025-05-21
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References

  1. European Centre for Disease Prevention and Control (ECDC), World Health Organization Regional Office for Europe. HIV/AIDS surveillance in Europe 2017 - 2016 data. Stockholm: ECDC; 2017. Available from: https://ecdc.europa.eu/sites/portal/files/documents/20171127-Annual_HIV_Report_Cover%2BInner.pdf
  2. Robert Koch Institut. Schätzung der Zahl der HIV-Neuinfektionen und der Gesamtzahl von Menschen mit HIV in Deutschland. Stand Ende 2016. [Estimation of the number of new HIV infections and of the total number of people living with HIV in Germany. Data until end of 2016]. Epidemiologisches Bulletin. 2016;47:531-45. German. https://doi.org/10.1056/NEJMoa1011205 
  3. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587-99.  https://doi.org/10.1056/NEJMoa1011205  PMID: 21091279 
  4. McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet. 2016;387(10013):53-60.  https://doi.org/10.1016/S0140-6736(15)00056-2  PMID: 26364263 
  5. Molina JM, Capitant C, Spire B, Pialoux G, Cotte L, Charreau I, et al. On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med. 2015;373(23):2237-46.  https://doi.org/10.1056/NEJMoa1506273  PMID: 26624850 
  6. Marcus JL, Hurley LB, Nguyen DP, Silverberg MJ, Volk JE. Redefining human immunodeficiency virus (HIV) preexposure prophylaxis failures. Clin Infect Dis. 2017;65(10):1768-9.  https://doi.org/10.1093/cid/cix593  PMID: 29020235 
  7. Spinner CD, Hanhoff N, Krznaric I, Knecht G, Kuemmerle T, Ruesenberg R, et al. 2016 PREP attitudes in Germany: high awareness and acceptance in MSM at risk of HIV. Infection. 2018;46(3):405-8.  https://doi.org/10.1007/s15010-018-1127-3  PMID: 29478091 
  8. WEBAPO InfoSystem.Fürth:LAUER-FISCHER GmbH. [Accessed :19 Jul 2017]. Available from: https://www.cgm.com/lauer-fischer/loesungen_lf/lauer_taxe_lf/webapo_infosystem_lf/webapo_infosystem.de.jsp
  9. Nichols BE, Boucher CAB, van der Valk M, Rijnders BJA, van de Vijver DAMC. Cost-effectiveness analysis of pre-exposure prophylaxis for HIV-1 prevention in the Netherlands: a mathematical modelling study. Lancet Infect Dis. 2016;16(12):1423-9.  https://doi.org/10.1016/S1473-3099(16)30311-5  PMID: 27665989 
  10. van Sighem A, Boender S, Wit F, Smit C, Master A, Reiss P. HIV monitoring report 2017. Human immunodeficiency virus (HIV) infection in the Netherlands. Amsterdam: Stichting HIV Monitoring; 2017. Available from: https://www.hiv-monitoring.nl/application/files/2015/3312/7799/2017_HIV_Monitoring_Report_updated_version.pdf
  11. Robert Koch Institut. Schätzung der Prävalenz und Inzidenz von HIV-Infektionen in Deutschland. Stand Ende 2014. [Estimation of the prevalence and incidence of HIV infections in Germany. Data from end 2014]. Epidemiologisches Bulletin. 2015;45:475-90. German.
  12. Lodi S, Phillips A, Touloumi G, Geskus R, Meyer L, Thiébaut R, et al. Time from human immunodeficiency virus seroconversion to reaching CD4+ cell count thresholds <200, <350, and <500 Cells/mm3: assessment of need following changes in treatment guidelines. Clin Infect Dis. 2011;53(8):817-25.  https://doi.org/10.1093/cid/cir494  PMID: 21921225 
  13. Sood N, Wagner Z, Jaycocks A, Drabo E, Vardavas R. Test-and-treat in Los Angeles: a mathematical model of the effects of test-and-treat for the population of men who have sex with men in Los Angeles County. Clin Infect Dis. 2013;56(12):1789-96.  https://doi.org/10.1093/cid/cit158  PMID: 23487387 
  14. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Antiretroviral Therapy for the Prevention of HIV-1 Transmission. N Engl J Med. 2016;375(9):830-9.  https://doi.org/10.1056/NEJMoa1600693  PMID: 27424812 
  15. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493-505.  https://doi.org/10.1056/NEJMoa1105243  PMID: 21767103 
  16. Donnell D, Baeten JM, Kiarie J, Thomas KK, Stevens W, Cohen CR, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet. 2010;375(9731):2092-8.  https://doi.org/10.1016/S0140-6736(10)60705-2  PMID: 20537376 
  17. Marcus U, Hickson F, Weatherburn P, Schmidt AJEMIS Network. Estimating the size of the MSM populations for 38 European countries by calculating the survey-surveillance discrepancies (SSD) between self-reported new HIV diagnoses from the European MSM internet survey (EMIS) and surveillance-reported HIV diagnoses among MSM in 2009. BMC Public Health. 2013;13(1):919.  https://doi.org/10.1186/1471-2458-13-919  PMID: 24088198 
  18. Deutsche AIDS-Gesellschaft (DAIG). Österreichische AIDS-Gesellschaft. Deutsch-Österreichische Leitlinien zur antiretroviralen Therapie der HIV-Infektion. [German-Austrian guidelines on the antiretroviral therapy of HIV infection]. Version 7. DAIG; 2017. German. Available from: https://daignet.de/site-content/hiv-therapie/leitlinien-1/deutsch-oesterreichische-leitlinien-zur-antiretroviralen-therapie-der-hiv-1-infektion
  19. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. 4th edition. Oxford: Oxford University Press; 2015. ISBN: 9780199665884
  20. Mostardt S, Hanhoff N, Wasem J, Goetzenich A, Schewe K, Wolf E, et al. Cost of HIV and determinants of health care costs in HIV-positive patients in Germany: results of the DAGNÄ K3A Study. Eur J Health Econ. 2013;14(5):799-808.  https://doi.org/10.1007/s10198-012-0425-4  PMID: 22990377 
  21. Federal Office of Statistics (Statistisches Bundesamt). Harmonisierter Verbraucherpreisindex (inkl. Veränderungsraten): Deutschland, Jahre. [Harmonised consumer price index (including rates of change)]. Wiesbaden: Statistisches Bundesamt. [Accessed: 19 Jul 2017]. German. Available from: https://www-genesis.destatis.de/genesis/online/data;jsessionid=F50037A5E2FCEDC8499216ECFCAE0D2F.tomcat_GO_2_3?operation=begriffsRecherche&suchanweisung_language=de&suchanweisung=Harmonisierter+Verbraucherpreisindex.
  22. Abteilung für Infektionsepidemiologie. HIV-1 Serokonverterstudie. [HIV-1 seroconverter study]. Berlin: Robert Koch-Institut. [Accessed: 17 Oct 2017]. German. Available from: https://www.rki.de/DE/Content/InfAZ/H/HIVAIDS/Studien/SeroKon/SeroKon_node.html Accessed February 7th 2019
  23. Bill and Melinda Gates Foundation. Methods for Economic Evaluation Project (MEEP). London: NICE INternational; 2014. Available from: https://www.nice.org.uk/Media/Default/About/what-we-do/NICE-International/projects/MEEP-report.pdf
  24. Ong KJ, Desai S, Field N, Desai M, Nardone A, van Hoek AJ, et al. Economic evaluation of HIV pre-exposure prophylaxis among men-who-have-sex-with-men in England in 2016. Euro Surveill. 2017;22(42):22.  https://doi.org/10.2807/1560-7917.ES.2017.22.42.17-00192  PMID: 29067902 
  25. Cambiano V, Miners A, Dunn D, McCormack S, Ong KJ, Gill ON, et al. Cost-effectiveness of pre-exposure prophylaxis for HIV prevention in men who have sex with men in the UK: a modelling study and health economic evaluation. Lancet Infect Dis. 2018;18(1):85-94.  https://doi.org/10.1016/S1473-3099(17)30540-6  PMID: 29054789 
  26. National health care institute (Zorginstituut Nederland). Medicijnkosten. [Pharmacy purchase price]. Diemen: Zorginstituut Nederland. [Accessed: 8 Feb 2019]. Dutch. Available from: www.medicijnkosten.nl
  27. Spinner CD, Hanhoff N, Krznaric I, Knecht G, Kuemmerle T, Ruesenberg R, et al. 2016 PREP attitudes in Germany: high awareness and acceptance in MSM at risk of HIV. Infection. 2018;46(3):405-8.  https://doi.org/10.1007/s15010-018-1127-3  PMID: 29478091 
  28. Hoornenborg E, Achterbergh RC, van der Loeff MFS, Davidovich U, van der Helm JJ, Hogewoning A, et al. Men who have sex with men more often chose daily than event-driven use of pre-exposure prophylaxis: baseline analysis of a demonstration study in Amsterdam. J Int AIDS Soc. 2018;21(3):e25105.  https://doi.org/10.1002/jia2.25105  PMID: 29603900 
  29. Sax PE, Wohl D, Yin MT, Post F, DeJesus E, Saag M, et al. Tenofovir alafenamide versus tenofovir disoproxil fumarate, coformulated with elvitegravir, cobicistat, and emtricitabine, for initial treatment of HIV-1 infection: two randomised, double-blind, phase 3, non-inferiority trials. Lancet. 2015;385(9987):2606-15.  https://doi.org/10.1016/S0140-6736(15)60616-X  PMID: 25890673 
  30. Bickel M, Wyen C, Spinner CD, Baumgarten A, Jaeger H, Postel N, et al. Switch from tenofovir disoproxil fumarate (TDF)- to tenofovir alafenamide (TAF)-based regimens in clinical practice: real-world data of the German PROPHET cohort study. Conference Poster P112. HIV Glasgow; 28–31 October 2018, Glasgow, United Kingdom. J Int AIDS Soc. 2018;21(S8):e25187.
  31. McCormack PL. Dolutegravir: a review of its use in the management of HIV-1 infection in adolescents and adults. Drugs. 2014;74(11):1241-52.  https://doi.org/10.1007/s40265-014-0256-y  PMID: 25005775 
  32. Nichols BE, Sigaloff KC, Kityo C, Mandaliya K, Hamers RL, Bertagnolio S, et al. Averted HIV infections due to expanded antiretroviral treatment eligibility offsets risk of transmitted drug resistance: a modeling study. AIDS. 2014;28(1):73-83.  https://doi.org/10.1097/01.aids.0000433239.01611.52  PMID: 23921620 
  33. Kojima N, Davey DJ, Klausner JD. Pre-exposure prophylaxis for HIV infection and new sexually transmitted infections among men who have sex with men. AIDS. 2016;30(14):2251-2.  https://doi.org/10.1097/QAD.0000000000001185  PMID: 27314179 
  34. Hoornenborg E, Achterbergh RCA, Schim van der Loeff MF, Davidovich U, Hogewoning A, de Vries HJC, et al. MSM starting preexposure prophylaxis are at risk of hepatitis C virus infection. AIDS. 2017;31(11):1603-10.  https://doi.org/10.1097/QAD.0000000000001522  PMID: 28657964 
  35. Mantovani LG, Cortesi PA, Strazzabosco M. Effective but costly: How to tackle difficult trade-offs in evaluating health improving technologies in liver diseases. Hepatology. 2016;64(4):1331-42.  https://doi.org/10.1002/hep.28527  PMID: 26926906 
  36. Nichols BE, Boucher CA, van Dijk JH, Thuma PE, Nouwen JL, Baltussen R, et al. Cost-effectiveness of pre-exposure prophylaxis (PrEP) in preventing HIV-1 infections in rural Zambia: a modeling study. PLoS One. 2013;8(3):e59549.  https://doi.org/10.1371/journal.pone.0059549  PMID: 23527217 
  37. Brown AE, Mohammed H, Ogaz D, Kirwan PD, Yung M, Nash SG, et al. Fall in new HIV diagnoses among men who have sex with men (MSM) at selected London sexual health clinics since early 2015: testing or treatment or pre-exposure prophylaxis (PrEP)? Euro Surveill. 2017;22(25):30553.  https://doi.org/10.2807/1560-7917.ES.2017.22.25.30553  PMID: 28662762 
  38. Pilcher CD, Joaki G, Hoffman IF, Martinson FE, Mapanje C, Stewart PW, et al. Amplified transmission of HIV-1: comparison of HIV-1 concentrations in semen and blood during acute and chronic infection. AIDS. 2007;21(13):1723-30.  https://doi.org/10.1097/QAD.0b013e3281532c82  PMID: 17690570 
  39. Lodi S, Phillips A, Touloumi G, Geskus R, Meyer L, Thiébaut R, et al. Time from human immunodeficiency virus seroconversion to reaching CD4+ cell count thresholds <200, <350, and <500 Cells/mm3: assessment of need following changes in treatment guidelines. Clin Infect Dis. 2011;53(8):817-25.  https://doi.org/10.1093/cid/cir494  PMID: 21921225 
  40. Nakagawa F, Lodwick RK, Smith CJ, Smith R, Cambiano V, Lundgren JD, et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS. 2012;26(3):335-43.  https://doi.org/10.1097/QAD.0b013e32834dcec9  PMID: 22089374 
Cost-effectiveness and budget effect of pre-exposure prophylaxis for HIV-1 prevention in Germany from 2018 to 2058
<p class="citation"> <span>Citation style for this article:</span> <span class="meta-value authors"> <a href="/search?value1=David+A+M+C+van+de+Vijver&option1=author&noRedirect=true" class="nonDisambigAuthorLink">van de Vijver David A M C</a>, <a href="/search?value1=Ann-Kathrin+Richter&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Richter Ann-Kathrin</a>, <a href="/search?value1=Charles+A+B+Boucher&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Boucher Charles A B</a>, <a href="/search?value1=Barbara+Gunsenheimer-Bartmeyer&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Gunsenheimer-Bartmeyer Barbara</a>, <a href="/search?value1=Christian+Kollan&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Kollan Christian</a>, <a href="/search?value1=Brooke+E+Nichols&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Nichols Brooke E</a>, <a href="/search?value1=Christoph+D+Spinner&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Spinner Christoph D</a>, <a href="/search?value1=J%C3%BCrgen+Wasem&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Wasem Jürgen</a>, <a href="/search?value1=Knud+Schewe&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Schewe Knud</a>, <a href="/search?value1=Anja+Neumann&option1=author&noRedirect=true" class="nonDisambigAuthorLink">Neumann Anja</a></span>. Cost-effectiveness and budget effect of pre-exposure prophylaxis for HIV-1 prevention in Germany from 2018 to 2058. <a href="/content/ecdc">Euro Surveill.</a> 2019;24(7):pii=1800398. <a href="https://doi.org/10.2807/1560-7917.ES.2019.24.7.1800398" title="doi link" target="_blank">https://doi.org/10.2807/1560-7917.ES.2019.24.7.1800398</a> <span class="ES_Article_citation"> <span class="generated">Received</span>: 19 Jul 2018;&nbsp;&nbsp; <span class="generated">Accepted</span>: 28 Jan 2019 </span> </p>
/content/10.2807/1560-7917.ES.2019.24.7.1800398
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