BACKGROUND: Pre-exposure prophylaxis (PrEP) can be cost-effective in populations at high risk of HIV. While PrEP is the standard of care in Mexico, evidence of its cost-effectiveness is lacking. Therefore, we analysed the cost-effectiveness of PrEP among men who have sex with men (MSM) and transgender women (TGW).
METHODS: We developed a Markov model to examine the impact of scaling up PrEP through government and community clinics in MSM and TGW 15 years at high risk of HIV. Primary analysis evaluated generic emtricitabine-tenofovir disoproxil fumarate (F/TDF), branded emtricitabine-tenofovir alafenamide (F/TAF), and long-acting cabotegravir (CAB-LA) versus no-PrEP. Secondary analysis assessed F/TAF and CAB-LA versus F/TDF. The model was analysed from the healthcare perspective in a 15-year horizon (2022-2036). Incremental cost per quality-adjusted life-year (QALY) was compared against the national cost-effectiveness threshold (CET) of $10,165 per QALY gained. We varied key parameters in sensitivity analyses.
RESULTS: Annual costs of F/TDF, F/TAF and CAB-LA were $1,384, $2,220, and $1,384, respectively. If PrEP was scaled-up at 30% coverage and 80% uptake, F/TDF would avert 57,150 HIV transmissions and yield 138,892 incremental QALYs with an additional cost of $60 million compared with no-PrEP. F/TAF and CAB-LA would avert 55,000 HIV transmissions, achieving 134,018 and 133,951 incremental QALYs with additional $1.6 and $1.2 billion costs, respectively. Compared with no-PrEP, the incremental cost-effectiveness ratio (ICER) of F/TDF, F/TAF and CAB-LA were $4,427, $12,216, and $8,955 per QALY gained, with an 89%, 30% and 63% probability of cost-effectiveness (figure 1), respectively. F/TAF and CAB-LA were dominated by F/TDF. Results were robust to sensitivity analyses. Compared with F/TDF, CAB-LA was cost-effective at a maximum price of $788 and in populations with higher HIV incidence.

CONCLUSIONS: PrEP scale-up can have a substantial public health impact in Mexico over the following 15 years. To be cost-effective over F/TDF, CAB-LA should be half the F/TDF price.

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