Background: There is urgent need for effective HIV prevention methods that women can initiate. The CAPRISA 004\r\ntrial showed that a tenofovir-based vaginal microbicide had significant impact on HIV incidence among women.\r\nThis study uses the trial findings to estimate the population-level impact of the gel on HIV and HSV-2 transmission,\r\nand price thresholds at which widespread product introduction would be as cost-effective as male circumcision in\r\nurban South Africa.\r\nMethods: The estimated ââ?¬Ë?per sex-actââ?¬â?¢ HIV and HSV-2 efficacies were imputed from CAPRISA 004. A dynamic HIV/STI\r\ntransmission model, parameterised and fitted to Gauteng (HIV prevalence of 16.9% in 2008), South Africa, was used\r\nto estimate the impact of gel use over 15 years. Uptake was assumed to increase linearly to 30% over 10 years, with\r\ngel use in 72% of sex-acts. Full economic programme and averted HIV treatment costs were modelled. Cost per\r\nDALY averted is estimated and a microbicide price that equalises its cost-effectiveness to that of male circumcision\r\nis estimated.\r\nResults: Using plausible assumptions about product introduction, we predict that tenofovir gel use could lead to a\r\n12.5% and 4.9% reduction in HIV and HSV-2 incidence respectively, by year 15. Microbicide introduction is predicted\r\nto be highly cost-effective (under $300 per DALY averted), though the dose price would need to be just $0.12 to\r\nbe equally cost-effective as male circumcision. A single dose or highly effective (83% HIV efficacy per sex-act)\r\nregimen would allow for more realistic threshold prices ($0.25 and $0.33 per dose, respectively).\r\nConclusions: These findings show that an effective coitally-dependent microbicide could reduce HIV incidence by\r\n12.5% in this setting, if current condom use is maintained. For microbicides to be in the range of the most\r\ncost-effective HIV prevention interventions, product costs will need to decrease substantially.
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