On demand PrEP among MSM in the
Netherlands: a cost-effective approach for
preventing HIV-1 infections
Brooke Nichols
Department of Viroscience, Erasmus MC
Disclosures
Brooke Nichols has received research funding to her
institution from Gilead Sciences, ViiV Healthcare,
Merck, Janssen, and Boehringer Ingelheim
Background
 HIV epidemic still not under control
700-800 new infections/year among MSM in the
Netherlands
 New prevention strategies are still needed!
Background
 Two important new trials: pre-exposure
prophylaxis with tenofovir+emtricitabine
MSM
Study
Proud*
PrEP Type
Daily
* McCormack et al. Lancet 2015
Efficacy
86%
Background
 Two important new trials: pre-exposure
prophylaxis with tenofovir+emtricitabine
MSM
Study
Proud*
iPerGay
PrEP Type
Daily
On Demand**
Efficacy
86%
86%
* McCormack et al. Lancet 2015
** use of PrEP only around sexual contact
Objective
 What is impact of PrEP on the HIV-1
epidemic among MSM in the Netherlands?
How many infections prevented
Cost-effectiveness
Methods
 Used deterministic mathematical model
calibrated to the Dutch MSM HIV epidemic:
No HIV
Methods
 Used deterministic mathematical model
calibrated to the Dutch MSM HIV epidemic:
No HIV
Acute
Chronic
AIDS
Methods
 Used deterministic mathematical model
calibrated to the Dutch MSM HIV epidemic:
No HIV
Acute
Chronic
Treated
AIDS
Methods
 Used deterministic mathematical model
calibrated to the Dutch MSM HIV epidemic:
No HIV
No HIV
PrEP
Acute
Chronic
Treated
AIDS
Methods
 Used deterministic mathematical model
calibrated to the Dutch MSM HIV epidemic:
No HIV
No HIV
PrEP
Acute
Chronic
86% reduction
Treated
AIDS
Methods
 Median 4,500 MSM on PrEP every year
~2.5% of the MSM population in the
Netherlands
Predominantly highly sexually active MSM
Methods: Key Costs
Input
Daily PrEP
Yearly Cost per
Patient
€7,100
Methods: Key Costs
Input
Daily PrEP
PrEP on Demand
Yearly Cost per
Patient
€7,100
€3,550
Methods: Key Costs
Input
Daily PrEP
Yearly Cost per
Patient
€7,100
PrEP on Demand
€3,550
Treatment
€12,989
Methods: Key Costs
Input
Daily PrEP
Yearly Cost per
Patient
€7,100
PrEP on Demand
€3,550
Treatment
€12,989
Incremental cost-effectiveness ratio below €20,000 per quality adjusted
life year gained considered cost-effective
Future epidemic?
 We are unsure how the epidemic will behave in
the future!
 The clinical benefit for initiating treatment
immediately has been demonstrated.
START trial, NEJM 2015
Future epidemic?
 We are unsure how the epidemic will behave in
the future!
 The clinical benefit for initiating treatment
immediately has been demonstrated.
START trial, NEJM 2015
 Immediate treatment now recommended.
 Earlier treatment initiation is predicted to reduce HIV
epidemic in the future.
Future epidemic?
 A key determinant to future effectiveness of PrEP
is the impact of earlier treatment initiation on the
epidemic.
 Therefore, evaluated scenarios where:
 Epidemic remained stable
 Small decline in epidemic
 Moderate decline in epidemic
Results: Cumulative infections prevented
Stable epidemic
16.3% prevented
Results: Cumulative infections prevented
Stable epidemic
16.3% prevented
Low decrease
14.0% prevented
Results: Cumulative infections prevented
Stable epidemic
16.3% prevented
Low decrease
14.0% prevented
Moderate decrease
11.9% prevented
Results: Cost-effectiveness
Increase
HIV epidemic
Decrease
HIV epidemic
Daily PrEP, full price
Results: Cost-effectiveness
Increase
HIV epidemic
Decrease
HIV epidemic
Daily PrEP, full price
Daily PrEP, 50% reduction
in price
Results: Cost-effectiveness
Increase
HIV epidemic
Decrease
HIV epidemic
Daily PrEP, full price
Daily PrEP, 50% reduction
in price
On demand, full price
Results: Cost-effectiveness
Increase
HIV epidemic
Decrease
HIV epidemic
Daily PrEP, full price
Daily PrEP, 50% reduction
in price
On demand, full price
On demand, 50% reduction
in price
Conclusions
 PrEP will reduce the HIV epidemic among MSM in
the Netherlands
Conclusions
 PrEP will reduce the HIV epidemic among MSM in
the Netherlands
 On demand PrEP is cost-effective
Conclusions
 PrEP will reduce the HIV epidemic among MSM in
the Netherlands
 On demand PrEP is cost-effective
 Extent of epidemic reduction and costeffectiveness depends on the effect of earlier
treatment initiation
Acknowledgements
 Charles Boucher
 Bart Rijnders
 David van de Vijver
 Marc van der Valk
We gratefully acknowledge funding from:
- AIDS Fonds, the Netherlands
- European Union, CHAIN