Rolling Back PrEP Coverage Affects Both New Infections, Economic Cost: Patrick Sullivan, DVM, PhD

Patrick Sullivan, DVM, PhD, an infectious disease epidemiologist and professor of epidemiology at Emory University in Atlanta, Georgia, spoke about his recent analysis that revealed that modest reductions in coverage for pre-exposure prophylaxis (PrEP) could have major implications for both health care costs and an increased incidence of HIV.

This transcript has been lightly edited for clarity; captions are auto-generated.

Transcript

What were the results of your analysis evaluating cost of reducing PrEP coverage?

The question we asked was, if we start with the knowledge that from looking backwards in time and from looking at what happened as [PrEP] gained traction over a period of years, over a decade after it was introduced, we could really track and model that as PrEP coverage went up or in states that had higher levels of PrEP coverage—even if you take other things into account [like] what the trend looked like, how much viral suppression there was, the other things that might affect new diagnoses—that variable of the level of PrEP coverage, the percent of people who would benefit from PrEP who were taking it, was highly associated with what happened in new diagnoses. In that prior analysis, we actually found that the 10 states that had the lowest level of coverage—meaning just of all the people who might benefit from PrEP, the lowest percent taking it—those states actually experienced increases in new HIV diagnoses. Then with each increment of higher PrEP coverage, there was just a stair-stepping down to the group with the highest PrEP coverage that experienced dramatic reductions in new HIV infections.

We started with that knowledge, and we now understood the mathematical relationship between levels of PrEP coverage, how we take viral suppression into account, and what's likely to happen, or what would be predicted to happen with new HIV infections. We put all that together. We found that even small reductions in PrEP access, even if it was in the neighborhood of 3%, would lead to about 8600 preventable HIV infections, so infections that we would have averted with a higher level of PrEP coverage but didn't. That would speak to a cost of $3.6 billion in lifetime medical cost for those people living with HIV. We looked at some different scenarios. We looked at a high, bad outcome scenario of a 10% reduction in PrEP: 27,000 new HIV infections, $11.3 billion in extra costs. And even 2%—a very modest reduction—would still be 5200 new HIV infections, $2.2 billion in costs. The bottom line is, you don't have to have big erosions in PrEP coverage to have big impacts on people's health, most importantly. But if this is being done in the name of fiscal responsibility, it's also a fiscally irresponsible decision to take away prevention methods that actually save health care dollars. It's just hard to see where there's a win in this strategy of taking money away from an intervention that saves us money.