Dynamic Choice HIV Prevention Could Lead to Reduced Incidence

A projected decrease in HIV incidence of one-third over 10 years is possible when those at high risk of contracting the virus are offered structured choices for pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP), including long-acting cabotegravir. This option can help to reduce costs of care across Africa, according to a study published in Lancet HIV.¹

Cost-effectiveness may increase when those at increased risk of HIV are offered cabotegravir for use as PrEP | Image credit: wladimir1804 - stock.adobe.com

The incidence of HIV remains high in Africa despite some decline across the region. Dynamic choice HIV prevention (DCP) is an approach to preventing HIV that aims to offer PEP and PrEP of daily oral tenofovir disoproxil fumarate plus emtricitabine to men and women who have an increased risk of HIV. With the availability of cabotegravir, an injection of PrEP taken 6 times per year,² DCP could offer this option in order to encourage long-term adherence to prevention methods. This study aimed to evaluate how cost-effective the DCP approach is when cabotegravir is offered for PrEP in east, central, southern, and west Africa.

The HIV Synthesis model was used for this study, with each model running a simulated population of 100,000 individuals 15 years or older. The simulation runs from 1989, which was the start of the HIV epidemic, to 2075, which is 50 years after the implementation of the intervention; variables are updated every 3 months.

Settings were used to reflect the subsettings within countries. Scenarios that were simulated using these settings included sticking with the status quo; introducing the DCP intervention with condoms, oral PrEP, and PEP; and introduction of DCP with long-acting cabotegravir. Disability-adjusted life-years (DALYs) were used to assess the long-term cost-effectiveness of the policies over 10 years and 50 years.

The proportion of individuals who had a PrEP indication and took PrEP was only a median of 4% in those without DCP in the simulation. This increased to 15% in those who had DCP without cabotegravir and more than doubled to 33% when those on the DCP were offered cabotegravir. The proportion of those aged 15 to 64 years with a PrEP indication was not different between the 3 groups. A total of 77% of those who were on DCP that offered cabotegravir were taking cabotegravir rather than an oral PrEP.

The incidence of HIV decreased with the increased usage of PrEP, as those with no DCP had an HIV incidence per 100 person-years of 0.51 in those aged 15 to 49 years. This decreased to 0.32 in those who were on DCP that included cabotegravir. This would result in a slightly higher percentage of people who were positive for HIV with less than 1000 copies per mL, increasing from 80% in the group without DCP to 82% in those in DCP with cabotegravir. However, HIV incidence with a viral load of more than 1000 copies per mL would decrease from 2.4% in the group without DCP to 1.9% in those offered cabotegravir.

An increase in annual discounted costs of $8.6 million (95% CI, $7.7-$9.4 million) would occur over 50 years in the group of DCP without cabotegravir and $13.2 million (95% CI, $11.6-14.8 million) in the group with DCP and cabotegravir when compared with the status quo. The least net DALYs were found in the no DCP group.

There were some limitations to this study. It is not certain that each setting-scenario is relevant to any setting in the regions of Africa. This study focused on regions rather than countries, which did not allow for any explorations on cost-effectiveness in certain countries. Only heterosexual sex was considered for the study. PEP was not distinguished from PrEP in this model, and efficacy of PEP was not estimated. The model was only run a single time for each sampled set of parameter values.

The authors concluded that the DCP intervention “has a high probability of being cost-effective in multiple settings should it be possible to source long-acting HIV prevention drugs at sufficiently low costs.”

References

1. Phillips AN, Hickey MD, Shade SB, et al. Dynamic choice HIV prevention with long-acting injectable cabotegravir pre-exposure prophylaxis in east, central, southern, and west Africa: a cost-effectiveness modelling analysis. Lancet HIV. Published online September 11, 2025. doi:10.1016/s2352-3018(25)00169-9

2. Bonavitacola J. Long-acting injectable cabotegravir effective in both ART, PrEP. AJMC^®. March 12, 2025. Accessed September 15, 2025. https://www.ajmc.com/view/long-acting-injectable-cabotegravir-effective-in-both-art-prep