Costs and outcomes of routine HIV oral pre-exposure prophylaxis implementation across different service delivery models and key populations in South Africa: a retrospective cohort study

Abstract

Background: Despite several service delivery models that aim to improve uptake and persistence of pre-exposure prophylaxis (PrEP) in sub-Saharan Africa, the full costs of daily oral PrEP provision in routine care settings remain largely unknown. We aimed to evaluate outcomes and costs of daily oral PrEP delivery among key and priority populations at in-facility and community outreach programmes in South Africa.

Methods: This retrospective cohort study was done at seven urban sites across South Africa with in-facility or community outreach PrEP service delivery models. We did top-down and bottom-up microcosting, from the provider perspective, of routine oral PrEP provision in programmes focusing on men who have sex with men (MSM), female sex workers, and adolescent girls and young women (aged 15-24 years) who initiated oral PrEP between March 12, 2018, and Aug 13, 2019. The primary outcome was PrEP in-hand at 6 months, defined as having sufficient PrEP drug dispensed at the last visit to have the drug available 6 months after PrEP initiation. A subset of enrolled participants with sufficient potential follow-up were included in a 12-month outcome analysis. We report the cost per client initiated on PrEP in 2021 US dollars.

Findings: We enrolled 1281 people aged at least 15 years who initiated oral PrEP in either in-facility or community outreach programmes between March 12, 2018, and Aug 13, 2019. The proportion of participants with PrEP in-hand at 6 months varied from 41·8% (95% CI 31·9-52·2; 41 of 98 participants) at one MSM-focused clinic to 0% (0-6·7; 0 of 53 participants) in an MSM-focused outreach programme. Among 633 clients receiving oral PrEP with the potential for 12 months follow-up, 86 (13·6%) had PrEP in-hand at 12 months. The mean average 6-month costs per client initiating oral PrEP ranged from US$29 (95% CI 26-31) to $590 (488-692), with higher costs generally observed for in-facility programmes ($152, 140-164) than for outreach programmes ($84, 79-88). The mean average monthly cost per client with PrEP in-hand at 6 months ranged from $18 (15-21) to $160 (126-194).

Interpretation: Costs and outcomes of daily oral PrEP provision across several populations and service delivery models in real-world settings show substantial variability. Policy makers should consider this variability when planning further scale-up of oral PrEP programmes in South Africa and the sub-Saharan Africa region to maximise opportunities to improve efficiency based on local context.

Funding: The US President's Emergency Plan for AIDS Relief, the US Agency for International Development, and the National Institutes of Health.