Background: Many countries are incorporating oral PrEP into their combination prevention strategies following WHO''s 2015 guidance on oral PrEP for individuals at substantial risk of contracting HIV. In an effort to inform oral PrEP policy and programs, the USAID-funded Health Policy Plus (HP+) project applied a new mathematical modeling approach to estimate the impact, cost, and cost-effectiveness of providing oral PrEP to different subpopulations in thirteen countries.
Methods: HP+ estimated HIV incidence by risk group and province and considered the impact of oral PrEP through 2030 in the context of the national HIV prevention program using the Incidence Patterns Model (IPM) and an adaptation of the Goals model that incorporated additional risk groups using adjustment factors based on incidence ratios derived from IPM. These two models are linked through a workbook in Microsoft Excel to develop targets and summarize cost and impact modeling results.
Results: In most cases, the vast majority of HIV infections averted by oral PrEP were achieved by focusing on female sex workers (FSW) and sero-discordant couples (SDC) (Fig 1).

Additional impact from rolling out oral PrEP, by country and rollout scenario, 2018-2030
[Additional impact from rolling out oral PrEP, by country and rollout scenario, 2018-2030]

In Mozambique and Swaziland, substantial additional impact, without a concomitant decrease in cost-effectiveness, was achieved when medium-risk adolescent girls and young women (AGYW) were also included. Patterns of relative impact and cost-effectiveness by individual risk group varied across countries, with cost per HIV infection averted ranging from US$1,216 in Lesotho for FSW to US$228,694 in Haiti for medium-risk AGYW. When considering oral PrEP in the context of scale-up of other interventions, PrEP is more impactful and cost-effective when scale-up of ART and VMMC is less. However, scaling up oral PrEP provides additional HIV infections averted even when countries reach 90-90-90 targets for ART and 90% coverage of VMMC among males ages 10-29.
Conclusions: Oral PrEP is an important component of combination prevention programs, given its potential to protect highly vulnerable and underserved populations. Even in the context of 90-90-90 achievement, our modeling results support oral PrEP scale-up for high-incidence populations. These data will be used to assist countries in rolling out PrEP, while taking into account considerations such as equity, human rights, and implementation realities.

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