Population-level impact of expanding PrEP coverage by offering long-acting injectable PrEP to MSM in three high-resource settings: a model comparison analysis.
Sarah E Stansfield, Jesse Heitner, Kate M Mitchell, Carla M Doyle, Rachael M Milwid, Mia Moore, Deborah J Donnell, Brett Hanscom, Yiqing Xia, Mathieu Maheu-Giroux, David van de Vijver, Haoyi Wang, Ruanne Barnabas, Marie-Claude Boily, Dobromir T Dimitrov
Author Information
Sarah E Stansfield: Fred Hutchinson Cancer Center, Seattle, Washington, USA. ORCID
Jesse Heitner: Massachusetts General Hospital, Boston, Massachusetts, USA.
Kate M Mitchell: HIV Prevention Trials Network Modelling Centre, Imperial College London, London, UK. ORCID
Carla M Doyle: Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montr��al, Qu��bec, Canada. ORCID
Rachael M Milwid: Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montr��al, Qu��bec, Canada.
Mia Moore: Fred Hutchinson Cancer Center, Seattle, Washington, USA.
Deborah J Donnell: Fred Hutchinson Cancer Center, Seattle, Washington, USA.
Brett Hanscom: Fred Hutchinson Cancer Center, Seattle, Washington, USA.
Yiqing Xia: Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montr��al, Qu��bec, Canada.
Mathieu Maheu-Giroux: Department of Epidemiology and Biostatistics, School of Population and Global Health, McGill University, Montr��al, Qu��bec, Canada. ORCID
David van de Vijver: Viroscience Department, Erasmus Medical Centre, Rotterdam, the Netherlands. ORCID
Haoyi Wang: Viroscience Department, Erasmus Medical Centre, Rotterdam, the Netherlands. ORCID
Ruanne Barnabas: Massachusetts General Hospital, Boston, Massachusetts, USA.
Marie-Claude Boily: MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK.
Dobromir T Dimitrov: Fred Hutchinson Cancer Center, Seattle, Washington, USA.
INTRODUCTION: Long-acting injectable cabotegravir (CAB-LA) demonstrated superiority to daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for HIV pre-exposure prophylaxis (PrEP) in the HPTN 083/084 trials. We compared the potential impact of expanding PrEP coverage by offering CAB-LA to men who have sex with men (MSM) in Atlanta (US), Montreal (Canada) and the Netherlands, settings with different HIV epidemics. METHODS: Three risk-stratified HIV transmission models were independently parameterized and calibrated to local data. In Atlanta, Montreal and the Netherlands, the models, respectively, estimated mean TDF/FTC coverage starting at 29%, 7% and 4% in 2022, and projected HIV incidence per 100 person-years (PY), respectively, decreasing from 2.06 to 1.62, 0.08 to 0.03 and 0.07 to 0.001 by 2042. Expansion of PrEP coverage was simulated by recruiting new CAB-LA users and by switching different proportions of TDF/FTC users to CAB-LA. Population effectiveness and efficiency of PrEP expansions were evaluated over 20 years in comparison to baseline scenarios with TDF/FTC only. RESULTS: Increasing PrEP coverage by 11 percentage points (pp) from 29% to 40% by 2032 was expected to avert a median 36% of new HIV acquisitions in Atlanta. Substantially larger increases (by 33 or 26 pp) in PrEP coverage (to 40% or 30%) were needed to achieve comparable reductions in Montreal and the Netherlands, respectively. A median 17 additional PYs on PrEP were needed to prevent one acquisition in Atlanta with 40% PrEP coverage, compared to 1000+ in Montreal and 4000+ in the Netherlands. Reaching 50% PrEP coverage by 2032 by recruiting CAB-LA users among PrEP-eligible MSM could avert >45% of new HIV acquisitions in all settings. Achieving targeted coverage 5 years earlier increased the impact by 5-10 pp. In the Atlanta model, PrEP expansions achieving 40% and 50% coverage reduced differences in PrEP access between PrEP-indicated White and Black MSM from 23 to 9 pp and 4 pp, respectively. CONCLUSIONS: Achieving high PrEP coverage by offering CAB-LA can impact the HIV epidemic substantially if rolled out without delays. These PrEP expansions may be efficient in settings with high HIV incidence (like Atlanta) but not in settings with low HIV incidence (like Montreal and the Netherlands).
