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Comparing the cost of six-month PrEP dispensing with interim HIV self-testing to the standard-of-care three-month PrEP dispensing with clinic-based testing in Kenya

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BACKGROUND: In sub-Saharan Africa, cost remains an important barrier to HIV pre-exposure prophylaxis (PrEP) access and delivery. Novel PrEP delivery models are needed that reduce costs but maintain PrEP initiation and continuation. The JiPime-JiPrEP trial tested six-month PrEP dispensing with interim HIV self-testing (HIVST) and found non-inferior HIV testing, PrEP refills, and PrEP adherence compared to standard-of-care (SOC) clinic-based PrEP dispensing every three months. We measured the cost of this model compared to SOC dispensing.
METHODS: Using activity-based micro-costing from the payer perspective, we estimated the unit cost of PrEP per person per month (PrEP month) in the intervention and SOC arms. We estimated these costs in two contexts: 1) as implemented the trial, and 2) as projected in Kenyan public clinics.We used data from budgets and expense reports, published documents, and key informantinterviews. We also collected time-and-motion measures to estimate personnel effort on clinical care, HIV testing and counselling, laboratory testing, and PrEP delivery. We estimated costs in 2019 United States dollars and excluded research-related costs.
RESULTS: From January to December 2019, trial participants accrued 644 PrEP visits (enrollment: 304, refill: 340) and were dispended 2952 months of PrEP (intervention: 2039, SOC: 913). PrEP delivery for intervention clients took a median of 152 minutes of personnel time projected over one year versus 216 minutes for SOC clients. In the trial, the unit cost per PrEP month was $27.93 for the intervention and $30.89 for the SOC. Most costs were from personnel (intervention: 25%; SOC: 31%), medication (intervention: 24%; SOC: 22%), and laboratory testing (intervention: 18%; SOC: 12%). The projected unit cost per PrEP month in public clinics was $13.50 for the intervention and $15.53 for the SOC, with higher costs of HIVST kits more than offset by personnel savings in the intervention.In both arms, the majority of costs were attributable to medication (48%) and laboratory testing (22%).
CONCLUSIONS: Six-month PrEP dispensing with interim HIVST demonstrated comparable and lower costs than SOC clinic-based dispensing every three months in Kenya, with decreased personnel time. Subsidies to lower the cost of PrEP and HIVST kits may increase the affordability of PrEP and should be considered.

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