CROI 2019 Abstract eBook

Abstract eBook

Poster Abstracts

identified in Malawi in 2017. 126,949 PRS were given to reach 6,023 new index positives, costing an annual $91,404. National scale-up of index HIVST in place of PRS would increase the number of people newly aware of their positive status by 8% per year nationally (17,545) at an annual cost of $401,795. Conclusion: Index HIVST is less expensive per person newly aware of their positive HIV status than PRS but more expensive per facility-confirmed positive. Interventions to improve facility linkage should be investigated prior to national rollout.

Empirical cost data on PrEP is essential for program planners to assess the cost- effectiveness and affordability of scaling up PrEP.

1083 COST-EFFECTIVENESS OF PREEXPOSURE PROPHYLAXIS AMONG ADOLESCENT SEXUAL MINORITY MALES

Li Yan Wang 1 , Deven T. Hamilton 2 , Eli Rosenberg 3 , Patrick S. Sullivan 3 , David A. Katz 2 , Richard Dunville 1 , Lisa C. Barrios 1 , Maria Aslam 1 , Steven M. Goodreau 2 1 CDC, Atlanta, GA, USA, 2 University of Washington, Seattle, WA, USA, 3 Emory University, Atlanta, GA, USA Background: The U.S. Food and Drug Administration recently approved pre- exposure prophylaxis (PrEP) for adolescents at high risk of HIV infection, but it remains unknown whether this is a cost-effective intervention for adolescent sexual minority males (ASMM) generally or for certain highest-risk subgroups. Building on a recent network modeling study of PrEP among ASMM, we estimated the cost-effectiveness of PrEP use in black and white ASMM in higher prevalence US settings. Methods: Based on the estimated number of infections averted and the number of ASMM on PrEP from the previous model and published estimates of PrEP costs, HIV treatment costs, and quality-adjusted life years (QALY) gained per infection averted, we estimated the cost-effectiveness of PrEP use in black and white ASMM over 10 years using a societal perspective and lifetime horizon. Effectiveness was measured as lifetime QALYs gained. Cost estimates included 10-year PrEP costs and lifetime HIV treatment costs saved. Cost- effectiveness was measured as cost per QALY gained. For our base-case analysis, we considered PrEP for 16-18-year-old ASMM, initiating PrEP 6 months after first anal intercourse, 40% coverage, adherence profiles from the ATN113 trial, and estimated baseline prevalence of 12.4% and 1.4% among black and white 18-year-old ASMM respectively. Multiple sensitivity analyses were performed to assess robustness of the results to uncertainty in the input parameter values and assumptions used. Results: Under base-case assumptions, PrEP use would yield a cost- effectiveness ratio (CER) of $33,064/QALY in black ASMM and $427,788/QALY in white ASMM. In all PrEP scenarios considered (2 eligibility criteria, 5 coverage levels, 2 adherence profiles), the CER ranged from $10,461/QALY-$45,997/QALY in black ASMM, and $372,306/QALY-$603,887/QALY in white ASMM. In 95% of 10,000 simulation trials of the multivariate sensitivity analysis, the CER of the base-case PrEP scenario ranged from cost-saving to $69,404/QALY in black ASMM and ranged from $170,305/QALY-$538,881/QALY in white ASMM. PrEP use was cost-effective (<$100,000/QALY) in black ASMM but not cost-effective in white ASMM in all scenarios considered. This difference was mainly driven by the difference in the underlying prevalence. Conclusion: PrEP use in higher risk ASMM can be a cost-effective HIV prevention intervention at current PrEP drug costs. Clinicians should consider black ASMM a priority group for PrEP access among adolescents. 1 University of Toronto, Toronto, ON, Canada, 2 St. Michael’s Hospital, Toronto, ON, Canada, 3 Johns Hopkins University, Baltimore, MD, USA, 4 University of the Western Cape, Cape Town, South Africa, 5 TB/HIV Care Association, Cape Town, South Africa Background: Key populations including cisgender female sex workers (FSW) face barriers that undermine broader programmatic efforts to achieve viral load suppression among people living with HIV. We estimated the potential onward transmissions that could stem from a failure to achieve viral load suppression among FSW living with HIV across subnational epidemics in Southern Africa Methods: We used a deterministic mathematical model of heterosexual HIV transmission to reproduce the epidemiologic features of HIV epidemics in Southern Africa from 1990 to 2016. The model included 2 age-groups; 7 risk-groups (including two strata of FSW and their clients and intermediate and lower risk female and males); and turn-over in sex work and periods of higher risk behaviours. We synthesized subnational and subgroup data on HIV prevalence, sexual partnerships, condom-use, and HIV cascades across South Africa, Lesotho, and eSwatini to parameterize the model and generate 10,000 plausible epidemic trajectories across subgroups. We estimated the transmission population attributable fraction (tPAF), defined as the cumulative fraction of new HIV infections among current FSW and clients; and in the Sharmistha Mishra 1 , Huiting Ma 2 , Sheree Schwartz 3 , Deliwe R. Phetlhu 4 , Vijayanand Guddera 5 , Nora West 3 , Carly Comins 3 , Harry Hausler 5 , Stefan Baral 3 , for the Siyamphambili Study Team

Poster Abstracts

1082 THE COST OF PrEP DELIVERY IN KENYAN ANTENATAL, POSTNATAL, AND FAMILY PLANNING CLINICS Allen Roberts 1 , Ruanne V. Barnabas 1 , Felix Abuna 2 , Harrison Lagat 2 , John Kinuthia 2 , Jillian Pintye 1 , Aaron Bochner 1 , Jared Baeten 1 , Grace John-Stewart 1 , Carol Levine 1 1 University of Washington, Seattle, WA, USA, 2 University of Washington in Kenya, Nairobi, Kenya Background: Integrating PrEP provision through routine ante-/post-natal care (ANC/PNC) and family planning (FP) clinics is a potential strategy for efficient PrEP delivery to women in high HIV burden settings. The cost of delivering PrEP through ANC/PNC and FP clinics is unknown. Methods: We estimated the incremental economic cost of PrEP delivery from the provider perspective within the PrEP Implementation for Young Women and Adolescents (PrIYA) program in western Kenya. We abstracted program data from November 2017 to June 2018 in 16 facilities and estimated annual numbers of PrEP screening and dispensation visits. We identified all within- and above-facility activities supporting PrEP delivery and measured clinical service time using time-and-motion studies. We obtained input costs from program budgets, expenditure records and staff interviews. We also projected costs under Ministry of Health (MOH) implementation assuming MOH salaries and PrEP supervision by county and sub-county health teams. Under this scenario, we explored the impact of task shifting PrEP screening to HIV counsellors, deferring creatinine (Cr) testing from initiation to first follow-up visit, and varying uptake (proportion of counseling encounters that result in PrEP initiation) and continuation (average number of follow-up visits among returning clients) on program costs. We report the cost per client-month of PrEP dispensed in 2017 USD. Results: For an annual program output of 24,005 screenings, 4198 PrEP initiations, and 4427 follow-up visits, the average cost per client-month was $27. Personnel, drugs, and lab tests comprised 43%, 25%, and 14% of program costs, respectively. In the MOH scenario assuming no changes in outputs, the projected cost per client-month of PrEP dispensed reduced to $17, with drugs (41%), personnel (33%), and lab testing (15%) accounting for the majority of costs. Deferring Cr testing and task shifting PrEP counseling reduced projected costs by 5% and 8%, respectively. Halving both PrEP uptake and continuation increased the cost per client-month of PrEP to $25, while doubling uptake and continuation lowered the cost to $13. Conclusion: The cost of PrEP delivery through ANC/PNC and FP was similar to costs reported for delivery to other key populations ($11-$44 per client-month). Streamlining service delivery and increasing volume may reduce unit costs.

1084 EPIDEMIC IMPACT OF SUSTAINED VIREMIA AMONG FEMALE SEX WORKERS IN SOUTHERN AFRICA

CROI 2019 426