Daily oral tenofovir-based pre-exposure prophylaxis (PrEP) has recently been shown to be an efficacious HIV prevention strategy for key populations at high risk of acquiring HIV-1, including serodiscordant couples. This thesis addresses the following research question: what is the projected impact and cost-effectiveness of PrEP for serodiscordant couples in sub-Saharan Africa, and would it be a worthwhile intervention? By using statistical analysis and mathematical modelling, I answer this question and provide recommendations for the optimisation of antiretroviral-based HIV prevention this population. In this thesis, I begin by exploring the effect of the reduced risk of herpes simplex virus type 2 (HSV-2) acquisition by means of PrEP on the outcomes of an intervention, but conclude that the supplementary benefit is unlikely to substantially alter the costeffectiveness. I also perform statistical analysis of daily adherence patterns to PrEP, according to electronic monitoring, from the Partners PrEP Study and the Partners Demonstration Project in Kenya and Uganda and find that adherence was high in both settings. Finally, I adapt a microsimulation model of serodiscordant couples in Africa to include realistic PrEP adherence patterns, HIV-1 transmission, external partnerships, and empirical costs. Using this model, I simulate the likely impact and cost-effectiveness of a PrEP intervention according to characteristics and behaviours of couples in the context of a clinical trial and a demonstration project. Overall, I conclude that a PrEP intervention could be cost-effective or cost-saving when targeted to high-risk couples, but is unlikely to be cost-effective if expected incidence is low. In addition, the utility of PrEP for serodiscordant couples could be compromised if the resources needed to find high-risk couples are expensive or if couples are not found easily.
| Identifer | oai:union.ndltd.org:bl.uk/oai:ethos.bl.uk:733051 |
| Date | January 2015 |
| Creators | Jewell, Britta |
| Contributors | Hallett, Timothy ; Cremin, Ide ; Pickles, Michael |
| Publisher | Imperial College London |
| Source Sets | Ethos UK |
| Detected Language | English |
| Type | Electronic Thesis or Dissertation |
| Source | http://hdl.handle.net/10044/1/55275 |
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