OBJECTIVES: Pre-exposure prophylaxis (PrEP) is a medication (Tenovofir disoproxil) taken to prevent human immunodeficiency virus (HIV) infection in individuals at high risk of contracting HIV. In 2017 the patent on the first PrEP medication, Truvada expired. This allowed for low-cost generics to enter the market, a significant development in the prevention of HIV. This systematic review was undertaken to review the cost-effectiveness of PrEP programmes.

METHODS: PubMed, Embase, CINAHL (EBSCOHost), Cochrane Library and grey literature sources were searched up to 2nd October 2018. Screening, data extraction and quality assessment (ISPOR & CHEC-list) were conducted independently by two reviewers.

RESULTS: Of 1,582 identified studies, 18 relevant studies from 10 countries were included. The majority of studies (n=17) investigated PrEP use in gay, bisexual and other men who have sex with men (MSM), while one study focused on people who inject drugs (PWID). Fifteen studies evaluated PrEP taken daily, and three studies assessed PrEP taken ‘on-demand’. Seven studies were at high risk of bias due to industry support. Outcomes were reported as incremental cost-effectiveness ratios (ICERs) using cost per quality-adjusted life years (QALYs) gained/saved, disability-adjusted life years and life years saved. The mean annual cost of PrEP was €6,543 and efficacy was >86% in 9 out of 17 MSM-based studies. PrEP was not considered a cost-effective intervention in the only PWID study (ICER: €269,366). In MSM studies reporting cost per QALYs, PrEP was considered cost saving in two studies, while six studies reported an ICER below €45,000/QALY, and three studies estimated an ICER above €45,000/QALY.

CONCLUSIONS: The key drivers pertaining to cost-effectiveness were the lifetime cost of HIV and the efficacy and cost of PrEP medication. The critical epidemiological factor impacting cost-effectiveness was the incidence of HIV. Cost-effectiveness was also affected by patient behaviours in terms of uptake, adherence and persistence.