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The relative cost-effectiveness of long-acting injectable cabotegravir versus oral pre-exposure prophylaxis: a modelled economic evaluation and threshold analysis in South Africa based on the HPTN 083 and 084 trials

Title
The relative cost-effectiveness of long-acting injectable cabotegravir versus oral pre-exposure prophylaxis: a modelled economic evaluation and threshold analysis in South Africa based on the HPTN 083 and 084 trials
Presenter
Gesine Meyer-Rath
Authors
L. Jamieson (1,2), L.F. Johnson (3), B.E. Nichols (4,2,1), S. Delany-Moretlwe (5), M.C. Hosseinipour (6,7), C. Russell (4,2), G. Meyer-Rath * (1,4)
Institutions
(1) University of Witwatersrand, Health Economics and Epidemiology Research Office, Johannesburg, South Africa, (2) Amsterdam University Medical Centre, Department of Medical Microbiology, Amsterdam, Netherlands, the, (3) University of Cape Town, Centre of Infectious Disease Epidemiology and Research (CIDER), Cape Town, South Africa, (4) Boston University School of Public Health, Department of Global Health, Boston, United States, (5) Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, (6) University North Carolina, Chapel Hill, United States, (7) UNC Project, Lilongwe, Malawi

BACKGROUND: Long-acting cabotegravir (CAB-LA), administered 2-monthly, is more effective at preventing HIV infection than daily oral tenofovir (TDF)/emtricitabine (FTC), but its cost-effectiveness in a high-prevalence setting is not known. We estimated the cost-effectiveness of CAB-LA compared to TDF/FTC in South Africa and determined the threshold price at which CAB-LA is as cost-effective as TDF/FTC.
METHODS: We used deterministic HIV transmission modelling, evaluating the impact of CAB-LA provision compared to scaling up standard-of-care, TDF/FTC, to adolescent girls, young women, female sex workers, adolescent boys, young men, and men who have sex with men. We estimated the average cost by population using ingredients-based costing (costs in 2021 USD). We model the cost-effectiveness over 2022-2041, assuming two coverage scenarios (medium, high), assuming higher uptake of CAB-LA compared to TDF/FTC throughout based on preference studies. Under CAB-LA we modelled two scenarios defined by average duration of use (minimum: same duration as TDF/FTC of 5-11 months; maximum: longer duration than TDF/FTC, 12-24 months). We compare scenarios to the current baseline of low TDF/FTC roll-out.
RESULTS: Across CAB-LA scenarios, 15%-28% of new HIV infections were averted over baseline compared to 5%-8% in oral TDF/FTC scale-up scenarios (Table 1). Assuming equivalent drug costs between CAB-LA and TDF/FTC, the incremental cost of CAB-LA to the HIV programme was higher than TDF/FTC (5%-14% vs 2%-4%) due to higher assumed uptake of CAB-LA. The cost per infection averted was $4,553-$6,803 (CAB-LA) and $6,053-$6,610 (TDF/FTC). The cost per CAB-LA injection needed to be less than twice that of a 2-month supply of TDF/FTC to remain as cost-effective, with threshold prices ranging between $8.99/injection (high coverage; maximum duration) and $14.21/injection (medium coverage; minimum duration).

CONCLUSIONS: CAB-LA is potentially game-changing for HIV prevention. However, for its implementation to be financially feasible across low- and middle-income countries with high HIV incidence, CAB-LA must be reasonably priced.