Lily Geidelberg1, Kate M Mitchell1, Michel Alary2,3,4, Aminata Mboup2,3, Luc Béhanzin3,5,6, Fernand Guédou3,5, Nassirou Geraldo5, Ella Goma-Matsétsé5, Katia Giguère2,3, Marlène Aza-Gnandji5, Léon Kessou7, Mamadou Diallo2,3, René K Kêkê8, Moussa Bachabi8, Kania Dramane6, Christian Lafrance3, Dissou Affolabi9,10, Souleymane Diabaté2,3,11, Marie-Pierre Gagnon3,12, Djimon M Zannou9,10, Flore Gangbo8,9,10, Romain Silhol1, Fiona Cianci13,14, Peter Vickerman14, Marie-Claude Boily1,3. 1. Medical Research Council Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom. 2. Département de Médecine Sociale et Préventive, Université Laval, Québec, Quebec, Canada. 3. Axe Santé des Populations et Pratiques Optimales en Santé, Centre de Recherche du CHU de Québec-Université Laval, Québec, Quebec, Canada. 4. Institut National de Santé Publique du Québec, Québec, Quebec, Canada. 5. Dispensaire IST, Centre de Santé Communal de Cotonou 1, Cotonou, Bénin. 6. École Nationale de Formation des Techniciens Supérieurs en Santé Publique et en Surveillance Épidémiologique, Université de Parakou, Parakou, Bénin. 7. Service de Consultance et Expertise Nouvelle en Afrique (SCEN AFRIK), Cotonou, Bénin. 8. Programme Santé de Lutte Contre le Sida (PSLS), Cotonou, Bénin. 9. Faculté des Sciences de la Santé, Université d'Abomey-Calavi, Cotonou, Bénin. 10. Centre National Hospitalier Universitaire HMK de Cotonou, Cotonou, Bénin. 11. Université Alassane Ouattara, Bouake, Côte d'Ivoire. 12. Faculté des Sciences Infirmières, Université Laval, Québec, Québec, Canada. 13. Health Protection Surveillance Center, Dublin, Ireland; and. 14. Population Health Sciences, University of Bristol, Bristol, United Kindom.
Abstract
BACKGROUND: Daily pre-exposure prophylaxis (PrEP) and treatment-as-prevention (TasP) reduce HIV acquisition and transmission risk, respectively. A demonstration study (2015-2017) assessed TasP and PrEP feasibility among female sex workers (FSW) in Cotonou, Benin. SETTING: Cotonou, Benin. METHODS: We developed a compartmental HIV transmission model featuring PrEP and antiretroviral therapy (ART) among the high-risk (FSW and clients) and low-risk populations, calibrated to historical epidemiological and demonstration study data, reflecting observed lower PrEP uptake, adherence and retention compared with TasP. We estimated the population-level impact of the 2-year study and several 20-year intervention scenarios, varying coverage and adherence independently and together. We report the percentage [median, 2.5th-97.5th percentile uncertainty interval (95% UI)] of HIV infections prevented comparing the intervention and counterfactual (2017 coverages: 0% PrEP and 49% ART) scenarios. RESULTS: The 2-year study (2017 coverages: 9% PrEP and 83% ART) prevented an estimated 8% (95% UI 6-12) and 6% (3-10) infections among FSW over 2 and 20 years, respectively, compared with 7% (3-11) and 5% (2-9) overall. The PrEP and TasP arms prevented 0.4% (0.2-0.8) and 4.6% (2.2-8.7) infections overall over 20 years, respectively. Twenty-year PrEP and TasP scale-ups (2035 coverages: 47% PrEP and 88% ART) prevented 21% (17-26) and 17% (10-27) infections among FSW, respectively, and 5% (3-10) and 17% (10-27) overall. Compared with TasP scale-up alone, PrEP and TasP combined scale-up prevented 1.9× and 1.2× more infections among FSW and overall, respectively. CONCLUSIONS: The demonstration study impact was modest, and mostly from TasP. Increasing PrEP adherence and coverage improves impact substantially among FSW, but little overall. We recommend TasP in prevention packages.
BACKGROUND: Daily pre-exposure prophylaxis (PrEP) and treatment-as-prevention (TasP) reduce HIV acquisition and transmission risk, respectively. A demonstration study (2015-2017) assessed TasP and PrEP feasibility among female sex workers (FSW) in Cotonou, Benin. SETTING: Cotonou, Benin. METHODS: We developed a compartmental HIV transmission model featuring PrEP and antiretroviral therapy (ART) among the high-risk (FSW and clients) and low-risk populations, calibrated to historical epidemiological and demonstration study data, reflecting observed lower PrEP uptake, adherence and retention compared with TasP. We estimated the population-level impact of the 2-year study and several 20-year intervention scenarios, varying coverage and adherence independently and together. We report the percentage [median, 2.5th-97.5th percentile uncertainty interval (95% UI)] of HIV infections prevented comparing the intervention and counterfactual (2017 coverages: 0% PrEP and 49% ART) scenarios. RESULTS: The 2-year study (2017 coverages: 9% PrEP and 83% ART) prevented an estimated 8% (95% UI 6-12) and 6% (3-10) infections among FSW over 2 and 20 years, respectively, compared with 7% (3-11) and 5% (2-9) overall. The PrEP and TasP arms prevented 0.4% (0.2-0.8) and 4.6% (2.2-8.7) infections overall over 20 years, respectively. Twenty-year PrEP and TasP scale-ups (2035 coverages: 47% PrEP and 88% ART) prevented 21% (17-26) and 17% (10-27) infections among FSW, respectively, and 5% (3-10) and 17% (10-27) overall. Compared with TasP scale-up alone, PrEP and TasP combined scale-up prevented 1.9× and 1.2× more infections among FSW and overall, respectively. CONCLUSIONS: The demonstration study impact was modest, and mostly from TasP. Increasing PrEP adherence and coverage improves impact substantially among FSW, but little overall. We recommend TasP in prevention packages.
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