Preferred age for medical circumcision of male children stratified by the parent's gender.

<p>Preferred age for medical circumcision of male children stratified by the parent's gender.</p

Correlates of willingness to circumcise male children for reduction of future risk for HIV.

<p>*Row percentages displayed; APR adjusted prevalence ratios.</p>†<p>Addition of age, religion, education level, and place of residence did not substantially affect estimates from the multivariable models.</p

Estimating the Cost-Effectiveness of Pre-Exposure Prophylaxis to Reduce HIV-1 and HSV-2 Incidence in HIV-Serodiscordant Couples in South Africa

<div><p>Objective</p><p>To estimate the cost-effectiveness of daily oral tenofovir-based PrEP, with a protective effect against HSV-2 as well as HIV-1, among HIV-1 serodiscordant couples in South Africa.</p><p>Methods</p><p>We incorporated HSV-2 acquisition, transmission, and interaction with HIV-1 into a microsimulation model of heterosexual HIV-1 serodiscordant couples in South Africa, with use of PrEP for the HIV-1 uninfected partner prior to ART initiation for the HIV-1 1infected partner, and for one year thereafter.</p><p>Results</p><p>We estimate the cost per disability-adjusted life-year (DALY) averted for two scenarios, one in which PrEP has no effect on reducing HSV-2 acquisition, and one in which there is a 33% reduction. After a twenty-year intervention, the cost per DALY averted is estimated to be $10,383 and$9,757, respectively – a 6% reduction, given the additional benefit of reduced HSV-2 acquisition. If all couples are discordant for both HIV-1 and HSV-2, the cost per DALY averted falls to $1,445, which shows that the impact is limited by HSV-2 concordance in couples.</p><p>Conclusion</p><p>After a 20-year PrEP intervention, the cost per DALY averted with a reduction in HSV-2 is estimated to be modestly lower than without any effect, providing an increase of health benefits in addition to HIV-1 prevention at no extra cost. The small degree of the effect is in part due to a high prevalence of HSV-2 infection in HIV-1 serodiscordant couples in South Africa.</p></div

Key assumptions and parameters used in the model.

<p>^aMean time elapsed between entering category (CD4 cell count reaching value of upper bound) and exiting category (CD4 cell count drops below value of lower bound).</p><p>^bBaseline transmission probability is from an asymptomatic, non-pregnant woman to an uncircumcised man.</p><p>Key assumptions and parameters used in the model.</p

HIV assays used, by study site.

<p>HIV assays used, by study site.</p

Difference in cost per DALY averted for two PrEP scenarios.

<p>The discounted cost per DALY averted for a 20-year PrEP intervention with no assumed protection against HSV-2 acquisition and with 33% protection (both relative to a baseline scenario of no PrEP and ART initiation at a CD4 count of 350 cells/μl). The inset is the difference between the two scenarios in the mean number of DALYs averted per couple over the intervention period. The horizontal lines represent WHO thresholds for cost-effectiveness at three times GDP ($34,320) and one times GDP ($11,440) for South Africa.</p

Sensitivity analysis for factors affecting the cost per DALY averted.

<p>Univariate sensitivity analysis for factors affecting the cost per DALY averted at the end of a 20-year PrEP intervention, with a baseline assumption of a 33% protection against acquisition of HSV-2 (the vertical line at $9,757). The bars titled <i>ART Initiation CD4 <500</i> and <i>ART Initiation Immediately</i> assume increased thresholds for ART initiation. The bar titled <i>PrEP Adherence</i> assumes HIV-uninfected individuals are 50$150/PY or $350/PY, and the <i>PrEP Program Cost Perspective</i> bar assumes that the cost of the PrEP intervention is separate from funding for treatment, and does not include savings from reduced ART need due to averted HIV infections.</p

Cumulative probability of visiting an HIV clinic.

<p>Results are overall among a) all HIV seropositive persons (n = 152) and b) those not already on ART at baseline (n = 120). After month one, for those on ART, follow-up was discontinued. The cumulative probability of visiting an HIV clinic by 3 months was 88.5% overall and 85.3% among those not already on ART at baseline (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051620#pone-0051620-g001" target="_blank">Figure 1a and 1b</a>, respectively).</p

Follow-up.

*<p>Cumulative % is estimated by the Kaplan-Meier method.</p

HIV test results.

<p>HIV test results.</p