Although a previous analysis has shown that the use of antiretroviral drugs for post-exposure prophylaxis (PEP) against HIV after suspected sexual exposure could be cost-effective, if restricted to regular partners of HIV-infected persons, to patients reporting unprotected receptive anal intercourse (including condom breakage), and possibly to cases in which there is a substantial likelihood that the partner is infected [1] the careful analysis by Low-Beer and colleagues [2] of the cost of providing PEP to high-risk men who have sex with men (MSM) in Vancouver British Columbia's West End is the first study to examine the affordability of this strategy. Their analysis indicates that making PEP available to this relatively small population of men could quickly exhaust available funding.
We have done some simple calculations to determine the affordability of providing PEP in the USA at the national level, and arrived at a similar conclusion. The 1997 budget for the US Centers for Disease Control and Prevention's (CDC) national HIV prevention program was just over US$600 million [3] If this money were instead directed solely at PEP programs, it would pay for approximately 550 000 treatments (at a cost of US$1092 for dual-drug PEP), which would prevent approximately 880 HIV infections in a high-risk MSM population with a 20% prevalence of HIV, assuming that PEP is 80% effective and that the probability of HIV transmission is 1% (more infections could be prevented if PEP were restricted to partners of men known to be infected). This represents only a small proportion of the 40 000 new HIV infections that occur in the USA each year [4] Although the number of infections that would occur in the absence of the CDC national prevention efforts is unknown, it is believed to exceed the relatively small number that could be averted through PEP alone [3]
Depending on the demand, making PEP available to persons who have experienced a potential exposure to HIV through sex or drug injection could be extremely expensive. The simple analysis presented above suggests that this money might be better spent on other strategies to prevent the spread of HIV [2,5]
Steven D. Pinkertona
David R. Holtgravea
James G. Kahnb
References
1. Pinkerton SD, Holtgrave DR, Bloom FR
Cost-effectiveness of post-exposure prophylaxis following sexual exposure to HIV. AIDS 1998, 12:1067–1078.
2. Low-Beer S, Weber AE, Bartholomew K
et al.
A reality check: the cost of making post-exposure prophylaxis available to gay and bisexual men at high sexual risk [Correspondence]. AIDS 2000, 14:325–326.
3. Holtgrave DR, Pinkerton SD.
Setting performance standards for a national HIV prevention program.Presented at the World AIDS Conference, Geneva, 28 June–3 July 1998.
4. Holmberg SD
The estimated prevalence and incidence of HIV in 96 large US metropolitan areas. Am J Public Health 1996, 86:642–654.
5. Kahn JG, Pinkerton SD, Paltiel AD
Postexposure prophylaxis following HIV exposure. JAMA 1999, 281:1269–1270.
