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The Relative Cost-Effectiveness of Long-Acting Injectable Cabotegravir Versus Oral Pre-Exposure Prophylaxis: A Modelled Economic Evaluation and Threshold Analysis in South Africa Based on the HPTN 083 and 084 Trials
18 Pages Posted: 1 Mar 2022
More...Abstract
Background: Long-acting injectable cabotegravir (CAB-LA), a 2-monthly drug, has been shown to be more effective at preventing HIV infection than daily oral tenofovir (TDF)/emtricitabine (FTC), but its cost-effectiveness in a high-prevalence setting is not known. We estimated the cost-effectiveness of CAB-LA compared to TDF/FTC in South Africa and determined the threshold price at which CAB-LA is as cost-effective as TDF/FTC.
Methods: We used a deterministic HIV transmission model to evaluate the impact of TDF/FTC and CAB-LA provision to adolescent girls, young women, female sex workers, adolescent boys, young men, and men who have sex with men. We estimated the average intervention cost by population using ingredients-based costing (reported in 2021 USD). We model cost-effectiveness over 2022-2041, assuming two coverage scenarios (medium, high), partly based on current TDF/FTC implementation in South Africa, but assuming higher uptake of CAB-LA compared to TDF/FTC throughout. Under CAB-LA we modelled two scenarios defined by duration of use (minimum: same duration as TDF/FTC; maximum: longer duration than TDF/FTC).
Findings: Across CAB-LA scenarios, 15%-28% of new HIV infections were averted over baseline (current TDF/FTC roll-out) compared to 5%-8% within oral TDF/FTC scenarios (Table 1). If CAB-LA drug costs were equal to that of TDF/FTC for the same 2-month period, the incremental cost of CAB-LA to the HIV programme was higher than TDF/FTC (5%-14% vs 2%-4%) due to higher assumed uptake of CAB-LA. The cost per infection averted was $6,053-$6,610 (TDF/FTC) and $4,471-$6,785 (CAB-LA). The cost per CAB-LA injection needed to be less than twice that of a 2-month supply of TDF/FTC to remain as cost-effective, with threshold prices ranging between $9.03/injection (high coverage; maximum duration) and $14.47/injection (medium coverage; minimum duration).
Interpretation: CAB-LA is potentially game-changing for HIV prevention. However, for its implementation to be financially feasible across low- and middle-income countries with high HIV incidence, CAB-LA must be reasonably priced.
Funding Information: This study was made possible by the generous support of the American people through Cooperative Agreements 72067419CA00004, from the United States Agency for International Development (USAID). Work toward this paper was also funded by the Bill & Melinda Gates Foundation (INV-019496). SDM and MH received funding support from National Institute of Allergy and Infectious Diseases (NIAID), Office of the Director (OD), National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA), and the National Institute of Mental Health (NIMH) under Award Numbers UM1AI068619 (HPTN Leadership and Operations Center), UM1AI068617 (HPTN Statistical and Data Management Center), and UM1AI068613 (HPTN Laboratory Center). Additional funding for the trial was provided by the Bill & Melinda Gates Foundation (OPP1154174) and ViiV Healthcare.
Declaration of Interests: We declare no competing interests.
Ethics Approval Statement: MISSING
Keywords: long-acting injectable cabotegravir, pre-exposure prophylaxis, cost-effectiveness analysis, HIV prevention, South Africa
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