The case for prevention - Primary HIV prevention in the era of universal test and treat: A mathematical modeling study

Katharine Kripke; Robyn Eakle; Alison Cheng; Sangeeta Rana; Kristine Torjesen; John Stover

doi:10.1016/j.eclinm.2022.101347

The case for prevention - Primary HIV prevention in the era of universal test and treat: A mathematical modeling study

EClinicalMedicine. 2022 Mar 14:46:101347. doi: 10.1016/j.eclinm.2022.101347. eCollection 2022 Apr.

Authors

Katharine Kripke¹, Robyn Eakle^{2

3}, Alison Cheng², Sangeeta Rana², Kristine Torjesen⁴, John Stover⁵

Affiliations

¹ Avenir Health, 6930 Carroll Ave., Suite 350, Takoma Park, MD 20912, USA.
² U.S. Agency for International Development, Washington, DC, USA.
³ Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
⁴ FHI 360, Durham, NC, USA.
⁵ Avenir Health, Glastonbury, CT, USA.

Abstract

Background: As antiretroviral therapy (ART) has scaled up and HIV incidence has declined, some have questioned the continued utility of HIV prevention. This study examines the role and cost-effectiveness of HIV prevention in the context of "universal test and treat" (UTT) in three sub-Saharan countries with generalized HIV epidemics.

Methods: Scenarios were created in Spectrum/Goals models for Lesotho, Mozambique, and Uganda with various combinations of voluntary medical male circumcision (VMMC); pre-exposure prophylaxis; and a highly effective, durable, hypothetical vaccine layered onto three different ART scenarios. One ART scenario held coverage constant at 2008 levels to replicate prevention modeling studies that were conducted prior to UTT. One scenario assumed scale-up to the UNAIDS treatment goals of 90-90-90 by 2025 and 95-95-95 by 2030. An intermediate scenario held ART constant at 2019 coverage. HIV incidence was visualized over time, and cost per HIV infection averted was assessed over 5-, 15-, and 30-year time frames, with 3% annual discounting.

Findings: Each prevention intervention reduced HIV incidence beyond what was achieved by ART scale-up alone to the 90-90-90/95-95-95 goals, with near-zero incidence achievable by combinations of interventions covering all segments of the population. Cost-effectiveness of HIV prevention may decrease as HIV incidence decreases, but one-time interventions like VMMC and a durable vaccine may remain cost-effective and even cost-saving as ART is scaled up.

Interpretation: Primary HIV prevention is still needed in the era of UTT. Combination prevention is more impactful than a single, highly effective intervention. Broad population coverage of primary prevention, regardless of cost-effectiveness, will be required in generalized epidemic countries to eradicate HIV.

Keywords: Cost-effectiveness; Goals model; HIV; Lesotho; Mathematical modeling; Mozambique; Pre-exposure prophylaxis; Prevention; Sub-Saharan Africa; Uganda; Universal Test and Treat; Vaccine; Voluntary Medical Male Circumcision; test, testing.