Best HIV Intervention: Test-and-Treat, PrEP, or Both?

In the United States, new HIV infections occur most often among men who have sex with men (MSM), African Americans, and adults aged 30 to 64 years. Because early detection prevents further infections, the CDC recommends routine screening and immediate treatment of all patients aged 13 to 64 years. This Test-and-Treat approach identifies new cases and initiates antiretroviral therapy (ART) promptly, but it may be too costly on a national scale, and it may increase ART resistance.

One alternative is pre-exposure prophylaxis (PrEP), with the combination of emtricitabine with tenofovir disoproxil fumarate. However, its cost effectiveness isn’t clear, either.

Now, an article published ahead-of-print in Clinical Infectious Diseases reports that Test-and-Treat and PrEP interventions are cost-effective alternatives to the status quo, which was testing with treatment initiation at CD4 <500 cells/mcL at the time the study was conducted.

The study’s authors employed an epidemiologic model of HIV incidence in MSM in Los Angeles. The model simulated the HIV epidemic in Los Angeles between 2000 and 2010 that was used in previous studies. The authors ran different interventions through the model to determine the discounted cost, quality-adjusted life-years (QALY) benefit, and incremental cost-effectiveness ratios of each intervention.

The results suggest that PrEP and Test-and-Treat are cost-effective compared to the status quo. These strategies cost $27,863 to $37,181 and $19,302 to $24,544 per QALY gained, respectively. The cost per QALY gained in this study is lower in than other studies because the authors assumed a higher community HIV prevalence.

Test-and-Treat is preferable for payers and programs that are constrained financially.

Combining both methods, when feasible, will have additive effects because the populations are distinct (eg, PrEP targets uninfected individuals, and Test-and-Treat tests all individuals and treats infected patients).

The model doesn’t account for HIV transmission by nonsexual routes such as needle sharing or HIV transmission to or from women.

PrEP is cost effective compared to our current handling of the HIV epidemic and is only slightly more expensive than Test-and-Treat methods. Nevertheless, even combining both of the interventions won’t stop new HIV infections completely. Behavioral interventions targeting diagnosis, treatment initiation, and adherence are necessary additional steps to curtail the HIV epidemic.