OA27.05
Background: Long-acting injectable rilpivirine (RPV) pre-exposure prophylaxis (PrEP) could be pivotal for optimizing PrEP effectiveness for HIV prevention. The impact of RPV PrEP on HIV transmission, mortality and the spread of drug resistance are unknown.
Methods: We examine the scale-up of RPV PrEP, ART and male medical circumcision (MMC) using a mathematical model of the HIV epidemic in KwaZulu-Natal (KZN). We compare a baseline scenario of ART and MMC scaled up to 80% coverage by 2017 to three scenarios of ART and MMC plus ten years of PrEP (90% efficacy; 35% cross-resistance) rollout starting in 2015:
a) 10% overall coverage of susceptible adults (20% of KZN's HIV budget at $165 per person-year of PrEP), either unprioritized or
b) prioritized to women aged 20–29; or
c) 80% coverage of high-risk adults (<2% of the HIV budget).
Outcomes include infections averted and drug resistance prevalence over ten years, and lifetime life-years (LY) lived, cost and cost-effectiveness. We classify scenarios as very cost-effective if the incremental cost per LY saved is less than South Africa's per capita GDP of $7,500, and cost-saving if costs decrease while life-years increase.
Results: Unprioritized PrEP averts 6.8% of infections over ten years and saves 1.9 million LY in the PrEP-exposed cohort ($605/LY saved). Age-prioritization improves PrEP's impact, averting 12.6% of infections and saving 3.5 million LY ($113/LY saved). Risk-prioritized PrEP reduces costs by 0.7%; it averts more infections (8.4%) and saves more LY (2.3 million) than unprioritized PrEP while using<10% as many person-years of PrEP. Drug resistance decreases with unprioritized or age-prioritized PrEP (1%; 1.7%), and increases by 2.5% with risk-prioritized PrEP compared to baseline (358,000 cases at 2025).
Conclusions: RPV PrEP is potentially very cost-effective, and may be cost-saving when prioritized to high-risk persons. Drug resistance from PrEP is limited compared to ART, though risk-prioritized PrEP may increase overall resistance.
