CROI 2025 Abstract eBook

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Poster Abstracts

weights. Finally, assuming 100% PrEP efficacy, we estimated the population impact of PrEP under two PrEP distribution scenarios: “optimal,” where PrEP is perfectly distributed to those at highest risk, and “suboptimal,” where only 50% of highest-risk individuals get PrEP (i.e., N PrEP prescriptions spread across the 2*N highest risk people). Results: The model predicted PrEP use by 1 million and 10-million individuals, respectively, would prevent 4,400 and ~16,000 sexually-acquired HIV cases [number needed to treat (NNT) = 230 and 620] with optimal distribution (Figure) and 3,400 and 10,400 transmissions (NNT=290 and 960) with suboptimal distribution. A secondary analysis assuming correlation between respondents’ sexual practices and partners’ HIV risk (optimal distribution) estimated PrEP use by 1- and 10-million would avoid ~12,000 and ~26,100 transmissions. Conclusions: Our model provides a framework to estimate the population impact of PrEP and its implications for public health policy. While model results vary depending on assumptions, findings strongly suggest that increases in PrEP uptake, substantially beyond prior CDC targets, may be required to achieve HIV elimination goals.

setting-scenarios HIV incidence rate ratios of 0.90 (0.64 – 1.19) and 0.66 (0.42 – 0.96) for DCP without and with Cab-LA, respectively. In the context of 10 million adults, both DCP policies lead to DALYs being averted (mean -12,500 and -35,000 for DCP without and with Cab-LA, respectively) but also to greater costs (+$8.4m and +$13.6m for DCP without and with Cab-LA, respectively). Over 50 years, DCP without Cab-LA is not predicted to be cost-effective (+4200 mean net DALYs; ICER if Cab-LA inclusion is not an option = $672/DALY averted. DCP with Cab-LA incurs the lowest mean net DALYs (-7700 per year over 50 years; ICER compared with status quo = $389), and is the cost-effective policy. Conclusions: Offering structured PrEP/PEP choice, including Cab-LA, could reduce HIV incidence by one-third over 10 years and is likely cost-effective across settings in east and southern Africa.

1294 Cost-Effectiveness of PrEP and Medications for Opioid Use Disorder in People Who Inject Drugs John Chiosi, John Giardina, Sarah E. Wakeman, Anne M. Neilan, Andrea L. Ciaranello Massachusetts General Hospital, Boston, MA, USA Background: People who inject drugs (PWID) in the US have high HIV incidence and fatal overdose rates, yet uptake is low for pre-exposure prophylaxis (PrEP; 1%) and medications for opioid use disorder (MOUD; 18%). Long-acting PrEP and MOUD formulations may improve uptake and adherence. Methods: Using the validated MYRIAD multimorbidity microsimulation model (accounting for impact of overdose and injection-related risk of HIV, hepatitis C, and bacterial infections), we simulated strategies for PWID with OUD at risk for HIV in the US (n = 1,582,233): oral PrEP ( TDF/FTC [TDF]: annual drug and program costs $1,224, HIV incidence reduction 49%), long-acting injectable PrEP ( cabotegravir [CAB]: $24,682, 66%; lenacapavir [LEN]: $39,490, 100%), and MOUD (HIV incidence reduction 54%) via opioid treatment program ( methadone [MET]: $6,552) and office-based treatment ( sublingual buprenorphine [BSL]: $1,433; extended-release injectable buprenorphine [BXR]: $26,013). We compared no PrEP/MOUD to strategies of only PrEP, only MOUD, and combinations of PrEP with MOUD. We projected 10-year outcomes for new HIV infections, deaths (from overdose, HIV, hepatitis C, and bacterial infections), life-years (LYs), costs, and incremental cost-effectiveness ratios (ICERs: difference in costs/difference in health benefits). Results: With no PrEP/MOUD, we project 13,402 new HIV infections, 385,085 deaths, 12.18 million LYs and costs of $291 billion over 10 years. Five strategies would be cost-saving versus no PrEP/MOUD (Figure, strategies within the grey boxes): MET (saving $74 billion), MET+TDF ($72 billion), MET+CAB ($7 billion), BSL ($60 billion), BSL+TDF ($57 billion). Two strategies fall on the cost effectiveness frontier when comparing LYs (Panel A): MET (12.62 million LYs, $217 billion) and MET+TDF (ICER $361,577/LY versus MET, exceeding a common cost-effectiveness threshold of $100,000/LY). Three strategies fall on the cost effectiveness frontier when comparing averted HIV infections (Panel B): MET (2,497 infections averted versus no PrEP/no MOUD), MET+TDF (ICER $2,168,406/ additional averted infection), and MET+LEN ($86,963,411/additional averted infection). Conclusions: Among PWID with OUD at risk for HIV, methadone, methadone with TDF/FTC or cabotegravir, and sublingual buprenorphine with or without TDF/FTC would gain life-years, avert HIV infections, and save money. Additional long-acting injectable formulations can avert additional HIV infections but may not be cost-effective at current drug costs.

Poster Abstracts

1293 Dynamic Choice HIV Prevention With Cabotegravir (CAB-LA): A Model-Based Cost-Effectiveness Analysis

Andrew N. Phillips 1 , Matt Hickey 2 , Starley Shade 2 , Jane Kabami 3 , James Ayieko 4 , Elijah Kakande 3 , Laura Balzer 5 , Nicole Sutter 2 , Loveleen Bansi-Matharu 1 , Jennifer Smith 1 , John Schrom 2 , Gabriel Chamie 2 , Diane V. Havlir 2 , Moses Kamya 6 , Maya Petersen 5 1 University College London, London, UK, 2 University of California San Francisco, San Francisco, CA, USA, 3 Infectious Diseases Research Collaboration, Kampala, Uganda, 4 Kenya Medical Research Institute, Kilifi, Kenya, 5 University of California Berkeley, Berkeley, CA, USA, 6 Makerere University College of Health Sciences, Kampala, Uganda Background: The SEARCH dynamic choice HIV prevention (DCP) intervention, including structured choice of biomedical prevention modality (oral PrEP, PEP, Cab-LA) with option to switch over time, increased time covered by biomedical prevention and reduced HIV incidence among men and women in randomized trials in Kenya and Uganda. We use HIV Synthesis, an existing individual-based HIV simulation model, to project long-term impact and cost-effectiveness of this approach in Africa. Methods: By sampling parameter values at the start of each model run we created 500 "setting-scenarios" reflecting uncertainty in assumptions and a range of characteristics representing those observed across east and southern Africa. For each setting-scenario, 3 policies over 10 and 50 years beginning 2024 were considered: (i) status quo, (ii) DCP with oral PrEP, PEP and condoms; (iii) DCP also including Cab-LA. We used empirical data from the DCP trials to inform the intervention’s impact on PrEP/PEP initiation and persistence, and hence HIV incidence, as well as costs. Cost-effectiveness analysis was from a healthcare perspective (using cost-effectiveness threshold US$500 per DALY averted). We calculated net DALYs averted for DCP with and without Cab-LA, relative to status quo, to reflect predicted policy impact on overall population burden of disease, and incremental cost effectiveness ratio (ICER). Results: The DCP interventions are predicted to increase the proportion of people with a current PrEP/PEP indication who take PrEP/PEP and hence reduce HIV incidence relative to status quo over 10 years; median (90% range) across

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