Comparative Effectiveness of Interventions to Improve the HIV Continuum of Care and HIV Preexposure Prophylaxis in Kenya: A Model-Based Analysis

BACKGROUND: In Western Kenya up to one-quarter of the adult population was human immunodeficiency virus (HIV)-infected in 2012. The Ministry of Health, Médecins Sans Frontières, and partners implemented an HIV program that surpassed the 90-90-90 UNAIDS targets. In this generalized epidemic, we compared the effectiveness of preexposure prophylaxis (PrEP) with improving 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 person-years. Improving continuum levels to 95-95-95 averted 21.5% of infections, PrEP averted 8.0%, and combining 95-95-95 and PrEP averted 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.