Epidemiological impact and cost-effectiveness of expanding formal PrEP provision to PrEP-eligible MSM expressing PrEP-intention in the Netherlands

Objective Reimbursed pre-exposure prophylaxis (PrEP) access in the Netherlands has reached its maximum capacity with a waiting-list of 3,000 men-who-have-sex-with-men (MSM) and 19,500 PrEP-eligible/intending MSM. This study models the epidemiological impact and cost-effectiveness of expanding PrEP provision to waiting-list and PrEP-eligible/intending MSM in the Netherlands, given the imminent national evaluation of the current PrEP programme in July 2023. Methods We calibrated a deterministic transmission model of HIV among MSM. Expanded PrEP provision was seeded in 01/2022, to achieve the coverage (varied at 25%,50%,75%, and 100%) for the waiting-list (n=3,000), and PrEP-eligible/intending group (n=19,500) by 01/2024. The epidemiological impact was modelled until 2030, while cost-effectiveness and the budget impact were calculated from a payer’s perspective over 40-years, and five-years, starting from 2022, respectively. Results Expanding PrEP provision leads to further reductions in HIV infections among MSM. Covering waiting-list and PrEP-eligible/intending MSM can avert a total of 11 (2.5%) up to 192 (45.1%) new infections by 2030. Expanding PrEP provision to over-75% of PrEP-eligible/intending MSM offers the possibility of ending the HIV epidemic by 2030. However, achieving this milestone comes with significant costs, with an incremental-cost-effectiveness-ratio of €164,100 per quality-adjusted-life-year and short-term costs of €1,074 million over five-years. Conclusions This study provides timely evidence for the upcoming national evaluation of the PrEP program in the Netherlands, supporting its continuation and further expansion. While expanding PrEP provision holds promise for HIV elimination, given the associated significant costs, careful consideration is crucial to balance efforts to end the HIV epidemic and the available resources.