Sticker Shock: PrEP Is Not Cost-Effective at Current Price, Health Economists Find

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For years, the U.S. HIV prevention community has known that pre-exposure prophylaxis (PrEP) is prohibitively expensive for many patients who need it. Now, new research presented at the 2019 National HIV Prevention Conference (NHPC) in Atlanta finds that not only is PrEP expensive for individual patients, it's also not cost-effective for the health system as a whole (Abstract 5440).

In general, health economists in the United States agree that an intervention is "cost-effective" if it costs less than $200,000 for every "quality-adjusted life year," or QALY.

But when Nidhi Khurana, Ph.D., prevention effectiveness fellow at the Centers for Disease Control and Prevention (CDC) crunched the numbers for PrEP, she found that it has an incremental cost-effectiveness ratio of $885,867 -- meaning the health care system spends more than $800,000 to keep someone alive, happy, and healthy for one year.

Although PrEP is an important HIV prevention tool that can help avert nearly 20% of new infections per year, "right now, we can't really say that PrEP is cost-effective," said Khurana, lead author of the NHPC paper.

"In order for this to make it cost-effective, we really need to decrease the cost of PrEP," Khurana said.

For this model, Khurana and her colleagues assumed a PrEP list price of $12,599, plus an additional cost of $1,538 for the PrEP program. The model estimated the cost of delivering PrEP from 2016 to 2020 and estimated the redeemed quality-of-life years from 2016 to 2060.

The numbers looked different when broken down by high-risk subgroup. For people who inject drugs, introducing PrEP at current care continuum levels would cost just over $800,000 per QALY gained -- so, about on par with the overall average cost-effectiveness. For men who have sex with men (MSM), the cost-effectiveness improves, dropping to $463,303 per QALY, but for heterosexuals at high risk for HIV, it's more than $3.5 million per QALY.

The numbers get worse once you consider national plans to scale up HIV prevention targets, at which point PrEP would cost $1.7 million per QALY across all high-risk groups.

"PrEP is very important from an individual's perspective [because] it can obviously prevent them from having HIV," said Khurana. But at its current price point, "we can't scale this up -- it's impossible."

How Much Would You Pay?

While Khurana's study reveals that PrEP isn't cost-effective in health economics terms, other research presented at NHPC sheds light on individual patients' willingness to pay for a once-daily HIV prevention pill.

The research, presented by Gordon Mansergh, Ph.D., of the CDC Division of HIV/AIDS Prevention, found that a majority of black and Latino MSM surveyed in 2014 were willing to take PrEP to prevent HIV (Abstract 6152). However, 17% of the men surveyed were willing to take PrEP but could not pay for it, 48% were willing to pay between $1 and $50 per month, and 27% were willing to pay more than $50 per month.

Truvada (emtricitabine/tenofovir disoproxil fumarate) was approved for PrEP in 2012. Since then, its list price has skyrocketed by 45%. Today, the full cost of a PrEP prescription is about $1,600 per month.

Though many insurance plans cover Truvada for PrEP, rising out-of-pocket costs mean the pill is out of reach even for Americans with health insurance. In addition, PrEP's high price has limited the impact of budget-strapped HIV prevention campaigns.

Within Mansergh's cohort of surveyed black and Latino MSM, certain demographics predicted which men were willing to pay a higher price for PrEP. For example, those who identified as bisexual and those with a four-year college degree were more willing to pay a higher price.

Currently, black and Latino MSM are among the subgroups at highest risk for HIV. Though there are caveats for Mansergh's research -- which included 605 MSM from Kansas City, Mo., Fort Lauderdale, Fla., and Chicago -- it offers a sense of the portion of black and Latino MSM who would be willing to pay for PrEP.

In today's pricing climate, the out-of-pocket cost of PrEP will exceed $50 per month for many eligible patients. Currently, the CDC estimates that 1.1 million people in the U.S. would be good candidates for PrEP. According to estimates from Gilead, the maker of Truvada, fewer than 200,000 people have received a prescription.

Sony Salzman is a freelance journalist reporting on health care and medicine, who has won awards in both narrative writing and radio journalism. Follow Salzman on Twitter: @sonysalz.