Background: Mozambique is a high-burden HIV country with a generalized epidemic. To assist the national HIV program in integrating oral PrEP into the country''s existing HIV prevention strategy, the USAID-funded Health Policy Plus (HP+) project developed a new mathematical modeling approach to estimate the impact and cost-effectiveness of different oral PrEP scale-up scenarios.
Methods: Three roll-out scenarios were developed to model the cost and impact of providing oral PrEP to female sex workers, serodiscordant couples, and medium-risk young women ages 18-24. HP+ used the Incidence Patterns Model and the Goals model to estimate HIV incidence by risk group and province and oral PrEP impact in the context of the national HIV prevention program through 2030. We developed an Excel-based tool to link the two models, set scale-up targets, and summarize the cost and impact results. In the modeled scenarios, oral PrEP coverage increased following a logistic growth curve that reached 50% of the target population by 2030.
Results: We estimated that targeting female sex workers, serodiscordant couples, and medium-risk young women will avert the most HIV infections without sacrificing much cost-effectiveness, compared to more narrowly targeted strategies. These estimates were sensitive to changes in oral PrEP adherence; strategies with lower adherence averted fewer infections and were less cost-effective. In terms of individual risk groups, the projected cost per HIV infection averted was lowest (i.e. most cost-effective) for serodiscordant couples and female sex workers at US$22,400 and US$27,700, respectively, and highest (i.e. least cost-effective) for medium-risk young women, at US$33,000. Providing oral PrEP to medium-risk young women was projected to have the greatest impact, averting 13,000 HIV infections. If Mozambique achieves its Fast Track 2030 targets, oral PrEP could avert 13,200 HIV infections; if the targets for other HIV prevention and treatment interventions are not met, the impact of oral PrEP would be higher.
Conclusions: We developed a modeling approach that provides policymakers with impact and cost-effectiveness data to guide decision-making on PrEP. Our modeling results encouraged the Mozambique MOH to consider providing oral PrEP to female sex workers, serodiscordant couples, and medium-risk young women, a high-incidence population not previously prioritized for oral PrEP rollout.

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