1. Finding the right target population for PrEP The cost-effectiveness of PrEP provision to adolescents and young women in South Africa
Gesine Meyer-Rath1,2, Lise Jamieson1, Rahma Leuner1, Leigh Johnson3
1 Health Economics and Epidemiology Research Office, University of the Witwatersrand, South Africa
2 Center for Global Health and Development, Boston University, United States of America
3 Centre for Infectious Disease Epidemiology and Research, Department of Public Health and Family Medicine, University of Cape Town, South Africa

2. Background
In October 2016, an estimated people were enrolled on PrEP in 30 countries, mostly in the United States
UNAIDS goal is to have 3 million on PrEP by 2020
In 2016, we were tasked by the PrEP technical task team convened by the South African National Department of Health to consider the cost and impact of offering PrEP to Modelled the epidemiological impact and cost effectiveness of PrEP provision to:
young women (20-24 years)
adolescents of both genders (15-19 years)
female sex workers (FSW)
with and without self-selection of the high-risk sub-population

3. Methods: coverage and impact
Epidemiological impact modelled in Thembisa (HIV transmission model for South Africa); custom made cost model; comparison of cost-effectiveness with HIV Investment Case
PrEP was scaled-up linearly from 2017 onwards to a target coverage of 18% for young women and adolescents and 95% for FSW by 2018/19
Some central assumptions regarding PrEP in Thembisa :
No stratification by adherence
Average duration of PrEP use after initiation 2 years
Effective use for 11 months per year; 1 interruption per year
40% reduction in risk of acquisition due to PrEP

4. Methods: cost and cost effectiveness
Unit cost of PrEP provision
based on information from the first demonstration projects to female sex workers (Project TAPS, Wits RHI) and MSM (ANOVA)
assumes generic drugs, lowest staff cadres, includes demand creation and targeting costs
Provider perspective (South African government); cost of the entire HIV programme
Cost-effectiveness of PrEP as cost per HIV infection averted over a 20-year time period ( ) over a baseline of currently available HIV interventions at constant coverage levels.

5. Results: Cost of PrEP [2016 USD] Young women (20-24)
First year
Every year thereafter
Drugs
$ 55
Staff
$ 80
$ 66
Labs
$ 9
$ 7
HTS
$ 56
$ 52
Overheads
$ 18
$ 17
Supplies
$ 2
Total cost
$ 219
$ 199
(range across populations)
($ )
($ )

6. Results: Impact on HIV incidence

7. Results: incremental cost of the hiv programme

8. Results: Cost-effectiveness (2017-36)
Young women
(20-24)
Female adolescents
(15-19)
Male adolescents
FSW
All
High risk
No. of person years on PrEP (millions)
9.5
1.6
6.5
1.7
5.2
2.3
1.4
Total cost, US$ (billions) 47 45 46
Incremental cost, US$ (billions)
(% change)
1.8
(3.9%)
0.2 (0.5%)
1.1 (2.4%)
0.2 (0.4%)
0.9 (2.0%)
0.4 (0.8%)
Total new HIV infections (millions)
4.34
4.36
4.25
4.27
4.31
4.32
HIV infections averted (thousands)
97.6 (2.3%)
78.2 (1.8%)
(4.5%)
167.4 (4.1%)
128.8 (3.1%)
(2.9%)
75.7 (1.8%)
ICER [US$/HIV averted]
$18,021
$2,877
$5,998
$1,053
$7,047
$2,929
$2,511
ICER [US$/life year saved]
$4,320
$703
$1,609
$286
$2,049
$866
$584

9. Results: Cost-effectiveness (2017-36)
Young women
(20-24)
Female adolescents
(15-19)
Male adolescents
FSW
All
High risk
No. of person years on PrEP (millions)
9.5
1.6
6.5
1.7
5.2
2.3
1.4
Total cost, US$ (billions) 47 45 46
Incremental cost, US$ (billions)
(% change)
1.8
(3.9%)
0.2 (0.5%)
1.1 (2.4%)
0.2 (0.4%)
0.9 (2.0%)
0.4 (0.8%)
Total new HIV infections (millions)
4.34
4.36
4.25
4.27
4.31
4.32
HIV infections averted (thousands)
97.6 (2.3%)
78.2 (1.8%)
(4.5%)
167.4 (4.1%)
128.8 (3.1%)
(2.9%)
75.7 (1.8%)
ICER [US$/HIV averted]
$18,021
$2,877
$5,998
$1,053
$7,047
$2,929
$2,511
ICER [US$/life year saved]
$4,320
$703
$1,609
$286
$2,049
$866
$584

10. Results: comparison with other interventions
ICER (USD/LYS)
Condom availability
Cost saving
Male medical circumcision
SBCC 1 (HCT, reduction in MSP) 4
ART at current guidelines 69
PMTCT 88
Universal treatment
129
Infant testing at 6 weeks
155
HCT for sex workers
238
PrEP (Adol F, high risk)
286
SBCC 2 (condoms)
363
SBCC 3 (condoms, HCT, MMC)
454
PrEP (FSW)
584
PrEP (YW, high risk)
703
PrEP (Adol M, high risk)
866
General population HCT
887
Infant testing at birth
998
HCT for adolescents
1,196
PrEP (Adol F, all)
1,609
PrEP (Adol M, all)
2,049
PrEP (YW, all)
4,320
Early infant male circumcision
1,453,592

11. Conclusions
Targeting high risk populations is similarly (or slightly less) effective than providing PrEP to all risk groups within a population
However, targeting high risk populations is at a much lower cost
Even though PrEP is relatively expensive, successful targeting of high risk groups can render it more cost effective or even cost-saving in the longer term
This is contingent on high-risk sub-populations successfully self-selecting for PrEP

12. implementation
June 2016: Launch of sex worker prevention programme including PrEP (20 demonstration sites)
PrEP for MSM and young women available through limited demonstration sites
Decision with regards to national PrEP roll-out to young women will be based on demonstration study data
Preliminary data:
Uptake: young women (36-98%) > MSM (19%) > FSW (7%)
Adherence: 40-70% (young women)
Plans:
2017: PrEP provision to young women through universities, mobile clinics around schools
Later: ANC + FP clinics

13. Challenges and limitations
Many unknowns remain:
Cost of routine care provision
Demand/ uptake by sub-population
Adherence/ effective use by sub-population
Is geographical targeting possible/ ethical?
Projections and budgets will be updated regularly

14. Thanks to… Dr Gabriela Gomez, LSHTM/ Project TAPS Dr Kevin Rebe
Ben Brown, ANOVA
Dr Hasina Subedar, NDoH
Dr Yogan Pillay, NDoH
Members of the NDoH PrEP working group