988    

Background:  In France, recommendations for post-exposure prophylaxis (PEP) were issued in 1995 for occupational exposure and extended to non-occupational exposure in 1998. PEP sentinel surveillance was set up in July 1999.

Methods:  We evaluated, from a social perspective, the cost of PEP per quality-adjusted life-year (QALY) gained using a decision tree. We used PEP surveillance data, literature derived data on per-act transmission probabilities, PEP efficacy, and HIV quality of life. HIV prevalence and lifetime cost of HIV care during the HAART era were derived from French studies. We assumed a 65-year life expectancy in full health in uninfected persons and a mean HIV survival of 22.5 years, given widespread use of HAART. Cost of PEP drugs and biological follow-up were derived from the French public sector. A 3% annual rate was used to discount future costs and effects.

Results:  From 1999 to 2003, 8958 PEP following occupational and non-occupational exposure were prescribed (heterosexual sex 47.6%; homosexual sex 28.4%; occupational exposure 23.4%; drug injection 0.6%). Of those, 2143 (27%) were exposed to a known HIV-infected source. Mean compliance was estimated at 75%. Overall, PEP was estimated to prevent 7.7 infections and saved 64.4 QALY at net cost of €6.2 million (€96,952/QALY). PEP was cost-saving (€–20,349/QALY) for men and women having receptive anal intercourse with HIV-infected partners. PEP was cost-effective for men having receptive anal intercourse with men of HIV unknown serostatus (€36 757/QALY), for drug users with HIV⁺ needle-sharing partners (€1853/QALY) and for health-care workers with contaminated deep needle-stick injury (€24,304/QALY). Vaginal intercourse with HIV-infected men and needle sharing with person of HIV unknown status were possibly cost-effective (€100,000 to < €200,000/QALY). All these exposures concerned only 1712 persons (19% of all prescriptions). Except for receptive anal intercourse between men, PEP was not cost-effective (cost-effectiveness ratio ranged from €250,000 to €30 million/QALY) where the serostatus of the source was unknown.

Conclusions:  While PEP is, if well targeted, an efficient use of resources, in France, it is frequently used in situations where it is not cost-effective. PEP should better target persons at high risk of contracting HIV.

Keywords: Cost-effectiveness analysis; Post-exposure prophylaxis; HIV