Comparative effectiveness of interventions to improve the HIV continuum of care and HIV Pre-Exposure Prophylaxis in Kenya: a model-based analysis.

BACKGROUND: In Western Kenya up to one quarter of the adult population was HIV-infected in 2012. The Ministry of Health, Médecins Sans Frontières (MSF) and partners implemented an HIV program that surpassed the 90-90-90 UNAIDS targets. In this generalized epidemic, we compared the effectiveness of Pre-exposure Prophylaxis (PrEP) with improving the continuum of care.

METHODS: We developed a dynamic microsimulation model to project HIV incidence and infections averted to 2030. We modeled 3 strategies compared to a "90-90-90" continuum of care base case: 1) Scaling up the continuum of care to 95-95-95, 2) PrEP targeting young adults, with 10% coverage, and 3) Scaling up to 95-95-95 and PrEP combined.

RESULTS: In the base case, by 2030 HIV incidence was 0.37/100 PY. Improving continuum levels to 95-95-95 averted 21.5% of infections, PrEP 8.0%, and combining 95-95-95 and PrEP 31.8%. Sensitivity analysis showed that PrEP coverage had to exceed 20% to avert as many infections as reaching 95-95-95.

CONCLUSIONS: In a generalized HIV epidemic with continuum of care levels at 90-90-90, improving the continuum to 95-95-95 is more effective than providing PrEP. Continued improvement in the continuum of care will have the greatest impact on decreasing new HIV infections.