Cost-Effectiveness of Long-Acting PrEP among MSM and/or TGW in Middle- and High-Income Countries, with Relevance for the Netherlands - A Literature Review

Abstract

Scientific Abstract

Background: Oral Pre-Exposure Prophylaxis (PrEP) has long been marketed around the world as an efficient method of preventing HIV infections. It is often targeted towards those at the highest risk of HIV infection, which in the Netherlands includes MSM (Men who have Sex with Men), TGW (Transgender Women), and people who inject drugs. However, realworld evidence shows that oral PrEP comes with drawbacks, such as how its protective effect directly depends on adherence to the daily oral regimen. Low adherence is still an issue among particular groups of individuals in the Netherlands, such as those from a lower socioeconomic background, those with a lower level of education, and those who live outside of urban areas. To tackle this obstacle, Long-Acting PrEP (LA-PrEP), administered as injections once every few months, has been considered, and it has proven to be more effective than (good adherence to) oral PrEP. However, the overall uptake of LAPrEP is much lower than oral PrEP in the Netherlands, which raises questions regarding its cost-effectiveness in the country. There is, in fact, limited evidence on the costeffectiveness of LA-PrEP formulations such as Cabotegravir LA (CAB-LA) and Lenacapavir (LEN-LA) in the Netherlands. Therefore, this review aimed to assess whether LA-PrEP is cost-effective in comparison to oral PrEP among MSM and/or TGW in comparable middleand high-income countries, and to examine the relevance of these findings for the Netherlands. Methods: Focused searches in PubMed and Embase databases retrieved six peer-reviewed scientific articles and one scientific poster. Results: All studies reported that LA-PrEP was more effective at preventing HIV-infections, averting HIV-related deaths, and gaining Quality-Adjusted Life Years (QALYs), but only three out of the seven studies reported LA-PrEP to be cost-effective compared to oral PrEP. Lower oral PrEP adherence, higher HIV incidence, and higher LA-PrEP coverage resulted in the highest Incremental Cost-Effectiveness Ratios (ICERs) for LA-PrEP. Conclusion: LA-PrEP of either CAB-LA or LEN-LA may be very efficient in reducing future HIV incidences and bringing the Netherlands out of its HIV-decline stall, but its broad expansion in the country is unlikely to be cost-effective. A more targeted approach, as well as a combined expansion of oral PrEP and LA-PrEP strategies, holds more promise of meeting cost-effectiveness criteria, but in any case, the primary barrier would be the price of LA-PrEP.