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INTRODUCTION: Affordable HIV prevention tools are needed in Eastern and Southern Africa (ESA). Several promising long-acting pre-exposure prophylaxis (LA-PrEP) products are available or in development. However, ESA settings face severe healthcare resource constraints. We aimed to estimate the threshold price at which LA-PrEP products could be cost-effective in three ESA settings. METHODS: We adapted an agent-based model, EMOD-HIV, to simulate LA-PrEP (monthly oral, 2- and 6-monthly injectable) rollout in South Africa, Zimbabwe and Kenya. Due to uncertainties about LA-PrEP use, we examined a range of coverages (5%-20% of HIV-negative sexually active adults) and extents to which LA-PrEP use will be concentrated among those most at risk (prioritized rollout from higher- to lower-risk groups vs. uniform rollout among sexually active adults). To evaluate a 20-year commitment to LA-PrEP delivery, we assumed LA-PrEP was scaled up to target coverage from 2025 to 2030 and maintained at target levels before ending in 2045. We estimated maximum per-dose and per-year LA-PrEP costs that achieve cost-effectiveness (<US500 per disability-adjusted life-year averted) over 35 years (until 2060), compared to a scenario of daily oral PrEP only. Sensitivity analyses varied PrEP scale-up speeds and eligible populations. RESULTS: Risk-prioritized LA-PrEP for 5% of adults was projected to avert 11-21% of HIV acquisitions across settings, with 3-5 times more HIV acquisitions averted and 3-5 times higher maximum cost compared to non-prioritized rollout. Six-monthly injectable PrEP supported the highest per-dose cost: in the scenario with the most cost-effective LA-PrEP use (5% risk-prioritized rollout), the maximum per-dose price in South Africa was 52. 99 (95% CI: 48. 82-57. 21), in Zimbabwe 14. 64 (95% CI: 12. 04-17. 38) and in western Kenya 7. 50 (95% CI: 6. 73-8. 27). For monthly oral PrEP, corresponding per-dose costs were 5. 02 (95% CI: 4. 67-5. 37), 1. 45 (95% CI: 1. 10-1. 79) and 0. 87 (95% CI: 0. 80-0. 93). Results were sensitive to eligible population and prioritization, and moderately sensitive to scale-up speed and product effectiveness. CONCLUSIONS: LA-PrEP is likely to require reduced pricing and/or risk-prioritized rollout to be cost-effective in ESA.
Kaftan et al. (Sat,) studied this question.