OBJECTIVES: Despite the high efficacy of oral pre-exposure prophylaxis (PrEP) in preventing HIV acquisition, uptake is below global targets in sub-Saharan Africa. Community-based oral PrEP provision using HIV self-testing (HIVST) has the potential to expand PrEP coverage. We modeled the budget impact of PrEP provision utilizing different HIV testing modalities in a pharmacy-based setting, including costs incurred and averted.

METHODS: We parameterized an agent-based network model, EMOD-HIV, to assess the undiscounted budget impact of PrEP scale-up in western Kenya between 2022-2026. We evaluated community-based PrEP provision using HIVST (oral-fluid, blood-based) and rapid diagnostic tests detecting antibodies (Ab RDT), compared to no PrEP provision. We assumed individuals 18-49 years with ≥1 sexual partner and screening HIV-negative were eligible to initiate PrEP. HIV test performance and financial costs were based on literature review and expert opinion. PrEP provision costs were derived from pharmacy-based implementation trials. Results are presented in 2021 $USD with 95% credible intervals (CI) from the healthcare perspective.

RESULTS: At an average PrEP coverage of 5%, our model projected to avert 17% of new HIV acquisitions among adults 18-49 years across scenarios. The population prevalence of nucleoside reverse transcriptase inhibitor resistance was 5%. The costs of implementing PrEP were similar using oral HIVST (US$327.4 million, 95% CI: US$302.4-US$346.5), blood HIVST (US$350.3 million, 95% CI: US$324.7-US$369.2), and Ab RDT (US$315.9 million, 95% CI: US$291.9-US$333.3). The difference in HIVST costs is attributed to different average commodity costs (oral: US$2.50, blood: US$5.00). Costs of care for HIV-related illness were lower in PrEP scenarios (≤12%) compared to the no PrEP scenario (43%). The largest component costs of PrEP scale-up were PrEP provision costs (49%-54%).

CONCLUSIONS: The estimated budget impacts of pharmacy-based PrEP scale-up were comparable across HIVST and RDT Ab testing modalities in western Kenya. Results can inform stakeholder decision-making for HIV-testing for PrEP implementation in community settings.