Cost thresholds for anticipated long‐acting HIV pre‐exposure prophylaxis products in Eastern and Southern Africa: a mathematical modelling study

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Abstract 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 (<US$500 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$52.99 (95% CI: $48.82–$57.21), in Zimbabwe $14.64 (95$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$4.67–$5.37),$1.45 (95% CI: $1.10–$1.79) and $0.87 (95$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.