There is optimism regarding the possibility of reducing HIV transmission to low levels,1, 2, 3 and this is the aim of Kenya's recent Prevention Revolution.4 However, despite the availability of several proven efficacy interventions, limited resources raise the question of what should and should not be included in an optimal portfolio of combination prevention in a given epidemiological context.
Pre-exposure prophylaxis (PrEP) works when used,5, 6 but PrEP is expensive because of the cost of delivery and monitoring. Therefore, PrEP needs to be prioritised for individuals at high risk of infection, in periods of high risk, and for those who will adhere well. Recent WHO guidance7 states that oral PrEP should be offered as an additional prevention choice for people at substantial risk of HIV infection.
The spread of HIV in Narobi has been well documented. The first cases of HIV in Nairobi were identified in 1984.8 Since then, the importance of key populations has been recognised,9 with retrospective analyses of saved specimens revealing that prevalence in female sex workers increased from 4% in 1981 to 65% in 1985.8 Given the high prevalence of sexually transmitted infections and almost no condom use, the initial spread of HIV within the female sex worker population was rapid and approximately half of uninfected female sex workers followed up in a cohort study acquired HIV within a year (1985–86).10 A cohort study11 in female sex workers showed that prevalence peaked at 81% in the late 1980s and subsequently declined. Concomitantly, transmission became established in the wider population.12
The HIV epidemic in the population of Nairobi as a whole is in decline, but a concentrated sub-epidemic persists in key populations. Men who have sex with men (MSM) have been receiving increasing attention as a key population,13, 14 and within the Nairobi MSM population, an exceptionally high incidence of HIV of approximately ten per 100 person-years has been observed in male sex workers.15, 16 Among female sex workers, although large declines in incidence have been observed, incidence remained at about two per 100 person-years overall in the period 2008–11.17
Research in context
Evidence before this study
We searched PubMed for cost-effectiveness analyses of pre-exposure prophylaxis (PrEP) published before July 7, 2016, with the terms “HIV” AND “Africa” and “PrEP” and “cost”, with no language restrictions. Much attention has focused on the potential cost-effectiveness of PrEP per se, and several studies compare the cost-effectiveness of PrEP and earlier antiretroviral therapy. A 2016 modelling study looked at optimal use of existing and future prevention technologies, including PrEP, for South Africa and found that scaling up of existing interventions (ie, male circumcision and early antiretroviral therapy) followed by intravaginal rings targeted to sex workers and vaccines, if and when they become available, was the most cost-effective way to reduce HIV transmission. A 2014 modelling study illustrated the additional effect which can be achieved for the same level of spending by means of a geographically prioritised approach, by exploring optimal allocation of resources for combination prevention including PrEP across each of Kenya's counties and largest cities. Here, we focus on combination prevention in Nairobi, specifically, providing a high-resolution representation and analysis of the local epidemiological context in Nairobi. Before this study, a comprehensive review was done to identify all relevant epidemiological, behavioural, and programme data to inform model structure and parameterise the model. We searched PubMed for studies published up to Sept 30, 2013, with the following terms: (“HIV”[MeSH Terms] OR “HIV”[All Fields]) AND (“Nairobi”[All Fields]). The titles and abstracts of all identified papers were screened for potential relevance. Additionally, relevant reports and grey literature were identified and included as appropriate.
Added value of this study
We provide a detailed representation of the HIV epidemic and existing interventions in female sex workers, MSM, male sex workers, and the wider population of Nairobi to identify optimal allocation of resources for combination prevention. We use realistic estimates of the cost of delivering PrEP to key populations in this setting, informed by a primary costing study. We indicate the level of spending required for PrEP for key populations to be included in an optimal portfolio of interventions.
Implications of all the available evidence
These analyses indicate that an optimal prevention portfolio for Nairobi should focus initially on condom promotion in MSM and male sex workers in particular, followed by improved antiretroviral therapy retention, earlier antiretroviral therapy, male circumcision, and PrEP, as the budget allows. Furthermore, male sex workers were found to be a priority population for a PrEP intervention in this setting.
Demonstration of clinical efficacy is not sufficient in itself for an intervention such as PrEP to be implemented and included in combination prevention;18 practical considerations for implementation must follow confirmation of efficacy. Demonstration projects provide important information on how to deliver PrEP effectively outside clinical trial settings. Whether PrEP can compete for resources against other prevention options is an important question (ie, whether PrEP is included in an optimally allocated budget, as opposed to defining whether PrEP could be cost-effective based on an arbitrary cost-effectiveness threshold). If PrEP cannot compete for financial resources, then the fact that PrEP works if used and could even be cost-effective might be irrelevant for optimal allocation of limited resources in the context of combination prevention.
In addition to improving and expanding existing interventions, PrEP provided to key populations at highest risk of acquisition could be a useful new intervention for key populations. We developed a mathematical model to find the optimal portfolio of existing and new prevention interventions to reduce incidence for a given budget and assessed the conditions under which PrEP could be included in an optimally allocated budget.