The cost-effectiveness of HIV pre-exposure prophylaxis among heterosexual men in South Africa: a cost-utility modelling analysis

INTRODUCTION: Heterosexual men are not considered a key population in the HIV response and are mostly absent from pre-exposure prophylaxis (PrEP) studies to-date. Yet South African men face considerable HIV risk. We estimate the incremental cost-effectiveness of providing oral PrEP, injectable PrEP, or a combination of both to heterosexual South African men to assess if providing PrEP would efficiently use resources.

METHODS: Epidemiological and costing models estimated the one-year costs and outcomes associated with PrEP use in three scenarios. PrEP uptake was estimated for younger (aged 18-24) and older (aged 25-49) men using a discrete choice experiment. Scenarios were compared to a baseline scenario of male condom use, while a health system perspective was used to estimate discounted lifetime costs averted per HIV infection. PrEP benefit was estimated in disability-adjusted life years (DALYs) averted. Uncertainty around the estimated incremental cost-effectiveness ratios (ICERs) were assessed using deterministic and probabilistic sensitivity analyses.

RESULTS: No PrEP intervention scenarios were cost-effective for both age-groups at a willingness-to-pay threshold of $1,175/DALY averted. The lowest ICER ($2,873/DALY averted) was for the provision of oral PrEP to older men, although probability of cost-effectiveness was just .26%. Results found that ICERs were sensitive to HIV incidence and antiretroviral coverage.

CONCLUSION: This study estimates that providing PrEP to heterosexual South African men is not cost-effective at current cost-effectiveness thresholds. Given the ICERs' sensitivity to several variables, alongside the heterogeneity of HIV infection among South African men, PrEP may be cost-effective for older men with high incidence and other subgroups based on locality and race. We recommend further investigation to better identify and target these groups.