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Cost-effectiveness of preexposure prophylaxis for HIV prevention for conception in the United States

Leech, Ashley A.a,b,c; Burgess, James F.c,d,*; Sullivan, Mege,f; Kuohung, Wendyg; Horný, Michalc,h,i; Drainoni, Mari-Lynnc,d,f,j; Christiansen, Cindy L.k; Linas, Benjamin P.e,f

doi: 10.1097/QAD.0000000000002014
Epidemiology and Social

Objective: The aim of this study was to investigate the value of coformulated Tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) for preexposure prophylaxis (PrEP) for conception in the U.S. and to identify scenarios in which ‘Undetectable = Untransmittable’ (U = U) may not be adequate, and rather, PrEP or assisted reproduction would improve outcomes.

Design: We developed a Markov cohort simulation model to estimate the incremental benefits and cost-effectiveness of PrEP compared with alternative safer conception strategies, including combination antiretroviral therapy (cART) alone for the HIV-infected partner and assisted reproductive technologies. We modelled various scenarios in which HIV RNA suppression in the male partner was less than perfect.

Setting: U.S. healthcare sector perspective.

Participants: Serodiscordant couples in the U.S. was composed of an HIV-infected male and HIV-uninfected female seeking conception.

Intervention: Economic analysis.

Main outcome measure(s): Cumulative risks of HIV transmission to women and babies, maternal life expectancy, discounted quality-adjusted life years (QALY), discounted lifetime medical costs and incremental cost-effectiveness ratios.

Results: cART with condomless intercourse limited to ovulation was the preferred HIV prevention strategy among women seeking to conceive with an HIV-infected partner who is HIV-suppressed. PrEP was not cost-effective for women who had partners who were virologically suppressed. When the probability of male partner HIV suppression was low and we assumed generic pricing of PrEP, PrEP was cost-effective, and sometimes even cost-saving compared with cART alone.

Conclusion: From a U.S. healthcare sector perspective, when the male partner was not reliably suppressed, PrEP became economically attractive, and in some cases, cost-saving.

aDepartment of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee

bCenter for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center

cDepartment of Health Law, Policy and Management, Boston University School of Public Health

dU.S. Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research

eDepartment of Medicine, Center for Infectious Diseases, Boston Medical Center

fDepartment of Medicine, Section of Infectious Diseases

gDepartment of Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts

hDepartment of Radiology and Imaging Sciences, Emory University School of Medicine

iDepartment of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia

jEvans Center for Implementation and Improvement Sciences, Boston University

kBoston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA.

Correspondence to Ashley A. Leech, PhD, MS, Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Avenue, Suite 1275, Nashville, Tennessee 37203, USA. Tel: +1 615 875 9642; e-mail:

Received 9 April, 2018

Accepted 27 July, 2018

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