Annals of Internal Medicine – 5 July 2016

Annals of Internal Medicine
5 July 2016, Vol. 165. No. 1

Original Research
Cost-Effectiveness of HIV Preexposure Prophylaxis for People Who Inject Drugs in the United States
Cora L. Bernard, MS; Margaret L. Brandeau, PhD; Keith Humphreys, PhD; Eran Bendavid, MD, MS; Mark Holodniy, MD; Christopher Weyant, MS; Douglas K. Owens, MD, MS; and Jeremy D. Goldhaber-Fiebert, PhD
Background: The total population health benefits and costs of HIV preexposure prophylaxis (PrEP) for people who inject drugs (PWID) in the United States are unclear.
Objective: To evaluate the cost-effectiveness and optimal delivery conditions of PrEP for PWID.
Design: Empirically calibrated dynamic compartmental model.
Data Sources: Published literature and expert opinion.
Target Population: Adult U.S. PWID.
Time Horizon: 20 years and lifetime.
Intervention: PrEP alone, PrEP with frequent screening (PrEP+screen), and PrEP+screen with enhanced provision of antiretroviral therapy (ART) for individuals who become infected (PrEP+screen+ART). All scenarios are considered at 25% coverage.
Outcome Measures: Infections averted, deaths averted, change in HIV prevalence, discounted costs (in 2015 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.
Results of Base-Case Analysis: PrEP+screen+ART dominates other strategies, averting 26 700 infections and reducing HIV prevalence among PWID by 14% compared with the status quo. Achieving these benefits costs $253 000 per QALY gained. At current drug prices, total expenditures for PrEP+screen+ART could be as high as $44 billion over 20 years.
Results of Sensitivity Analysis: Cost-effectiveness of the intervention is linear in the annual cost of PrEP and is dependent on PrEP drug adherence, individual transmission risks, and community HIV prevalence.
Limitation: Data on risk stratification and achievable PrEP efficacy levels for U.S. PWID are limited.
Conclusion: PrEP with frequent screening and prompt treatment for those who become infected can reduce HIV burden among PWID and provide health benefits for the entire U.S. population, but, at current drug prices, it remains an expensive intervention both in absolute terms and in cost per QALY gained.
Primary Funding Source: National Institute on Drug Abuse.


Addressing Infection Prevention and Control in the First U.S. Community Hospital to Care for Patients With Ebola Virus Disease: Context for National Recommendations and Future Strategies
Kristin J. Cummings, MD, MPH; Mary J. Choi, MD, MPH; Eric J. Esswein, MSPH, CIH; Marie A. de Perio, MD; Joshua M. Harney, MS, CIH; Wendy M. Chung, MD, MS; David L. Lakey, MD; Allison M. Liddell, MD; and Pierre E. Rollin, MD
Health care personnel (HCP) caring for patients with Ebola virus disease (EVD) are at increased risk for infection with the virus. In 2014, a Texas hospital became the first U.S. community hospital to care for a patient with EVD; 2 nurses were infected while providing care. This article describes infection control measures developed to strengthen the hospital’s capacity to safely diagnose and treat patients with EVD. After admission of the first patient with EVD, a multidisciplinary team from the Centers for Disease Control and Prevention (CDC) joined the hospital’s infection preventionists to implement a system of occupational safety and health controls for direct patient care, handling of clinical specimens, and managing regulated medical waste. Existing engineering and administrative controls were strengthened. The personal protective equipment (PPE) ensemble was standardized, HCP were trained on donning and doffing PPE, and a system of trained observers supervising PPE donning and doffing was implemented. Caring for patients with EVD placed substantial demands on a community hospital. The experiences of the authors and others informed national policies for the care of patients with EVD and protection of HCP, including new guidance for PPE, a rapid system for deploying CDC staff to assist hospitals (“Ebola Response Team”), and a framework for a tiered approach to hospital preparedness. The designation of regional Ebola treatment centers and the establishment of the National Ebola Training and Education Center address the need for HCP to be prepared to safely care for patients with EVD and other high-consequence emerging infectious diseases.