Cost-effectiveness of pre-exposure prophylaxis for HIV prevention among female sex workers in Ethiopia: a Markov model analysis

Background Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy for high-risk populations, such as female sex workers. However, its uptake in Ethiopia remains limited. Due to the scarcity of local evidence, a cost-effectiveness analysis is needed to inform the potential expansion of PrEP services nationwide. This study aimed to assess the cost-effectiveness of PrEP in preventing HIV infection among female sex workers in Ethiopia. Methods A static Markov model was adapted to analyze HIV transmission and disease progression in a hypothetical cohort of 1,000 female sex workers receiving PrEP. Primary data were collected to estimate the cost of providing PrEP to female sex workers, while most model parameters were obtained from the published literature. Cost-effectiveness was assessed by calculating the incremental cost-effectiveness ratio of the PrEP intervention compared to no PrEP use. The effectiveness of PrEP was measured in QALYs gained over the lifetime of the cohort, and the ICER was estimated to determine the cost-effectiveness of the intervention. One-way sensitivity and probabilistic sensitivity analysis were conducted to assess uncertainty in the model results. Result The estimated unit cost of PrEP per client per year was USD 137.7. The PrEP intervention resulted in an incremental cost of USD 1,202,379 and an incremental gain of 1,231.50 QALYs compared with no PrEP. At the current level of PrEP coverage, the incremental cost-effectiveness ratio (ICER) was 976.35 USD per QALY gained. Under full PrEP coverage, the ICER decreased to USD 107.25 per QALY gained. At this level, PrEP would be considered a cost-effective intervention based on the threshold used for the cost-effectiveness analysis. The cost-effectiveness of PrEP was highly sensitive to PrEP efficacy, the level of uptake, and the cost of antiretroviral therapy (ART). Conclusion Pre-exposure prophylaxis for HIV prevention in female sex workers is not cost-effective at the current low level of PrEP coverage in Ethiopia. However, if coverage is expanded to full uptake and a lifetime time horizon is considered, PrEP could be a cost-effective intervention in Ethiopia.