Cost-effectiveness of PrEP in HIV/AIDS control in Zambia: A stochastic league approach

Brooke E. Nichols, Rob Baltussen, Janneke H. Van Dijk, Phil E. Thuma, Jan L. Nouwen, Charles A.B. Boucher, David A.M.C. Van De Vijver

Research output: Contribution to journalArticlepeer-review

15 Scopus citations


Background: Earlier antiretroviral therapy initiation and pre-exposure prophylaxis (PrEP) prevent HIV, although at a substantial cost. We use mathematical modeling to compare the cost-effectiveness and economic affordability of antiretroviral-based prevention strategies in rural Macha, Zambia. Methods: We compare the epidemiological impact and cost-effectiveness over 40 years of a baseline scenario (treatment initiation at CD4 <350 cells/μL) with treatment initiation at CD4 <500 cells per microliter, and PrEP (prioritized to the most sexually active, or nonprioritized). A strategy is cost effective when the incremental cost-effectiveness ratio (ICER) is <$3480 (<3 times Zambian per capita GDP). Stochastic league tables then predict the optimal intervention per budget level. Results: All scenarios will reduce the prevalence from 6.2% (interquartile range, 5.8%-6.6%) in 2014 to about 1% after 40 years. Compared with the baseline, 16% of infections will be averted with prioritized PrEP plus treatment at CD4 <350, 34% with treatment at CD4 <500, and 59% with nonprioritized PrEP plus treatment at CD4 <500. Only treating at CD4 <500 is cost effective: ICER of $62 ($46-$75). Nonprioritized PrEP plus treating at CD4 <500 is borderline cost effective: ICER of $5861 ($3959-$8483). Initiating treatment at CD4 <500 requires a budget increase from $20 million to $25 million over 40 years, with a 96.7% probability of being the optimal intervention. PrEP should only be considered when the budget exceeds $180 million. Conclusions: Treatment initiation at CD4 <500 is a cost-effective HIV prevention approach that will require a modest increase in budget. Although adding PrEP will avert more infections, it is not economically feasible, as it requires a 10-fold increase in budget.

Original languageEnglish (US)
Pages (from-to)221-228
Number of pages8
JournalJournal of Acquired Immune Deficiency Syndromes
Issue number2
StatePublished - Jun 1 2014
Externally publishedYes


  • cost-effectiveness
  • pre-exposure prophylaxis
  • stochastic league tables
  • treatment as prevention

ASJC Scopus subject areas

  • Infectious Diseases
  • Pharmacology (medical)


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