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HIV PrEP currently too pricey to use in people who inject drugs


American College of Physicians

1. HIV PrEP currently too pricey to justify use in people who inject drugs
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HIV preexposure prophylaxis (PrEP) has individual and population health benefits, but the intervention is currently too expensive to implement in in people who inject drugs. The findings are published in Annals of Internal Medicine.

Injection drug users make up only about 1 percent of the U.S. adult population but account for approximately 10 percent of all new HIV infections. Daily oral PrEP has been proven effective for reducing HIV infection in injection drug users and the CDC has recommended PrEP as one prevention option for adult injection drug users at substantial risk of HIV acquisition. However, the cost and health benefits of implementing a national program are unclear.

Researchers developed a computer model of the U.S. HIV population to evaluate the public health benefit and cost of a national PrEP program for injection drug users. The model considered PrEP alone, PrEP with frequent screening, and PrEP with frequent screening and prompt treatment with antiretroviral therapy (ART) for those who become infected.

The model suggested that over 20 years, enrolling a quarter of HIV uninfected injection drug users in a PrEP + screening + ART program would be the optimal approach for reducing HIV infection. However, at current drug prices this approach would cost the U.S. an additional $44 billion, which is equivalent to annually spending 10 percent of the current federal budget for domestic HIV/AIDS on PrEP for people who inject drugs. In addition, the intervention would prevent about 21,500 new infections over 20 years, making it cost-prohibitive in both absolute terms and in cost per cost per quality-adjusted life years (QALY) gained.

The author of an accompanying editorial says that even at lower drug prices, HIV PrEP for injection drug users may not be an efficient use of HIV prevention resources. HIV is no longer deadly, but injection drug users face a high risk for overdose and death. Investments in access to naloxone therapy, medical insurance and detoxification programs, opioid agonist therapy, and needle exchange could possibly prevent HIV infections better than PrEP and also provide an immediate life-saving benefit.

Note: For an embargoed PDF, please contact Cara Graeff. To interview the lead author, Cora Bernard, please contact Beth Duff Brown at

2. No increased heart failure risk observed with saxagliptin or sitagliptin
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A retrospective cohort study found that patients taking saxagliptin or sitagliptin did not have a higher risk for heart failure compared to those taking other commonly-prescribed medications for type 2 diabetes. The findings are published in Annals of Internal Medicine.

Saxagliptin and sitagliptin are a class of oral antihyperglycemic medications called dipeptidyl peptidase-4 (DPP-4) inhibitors. Postmarketing trials have shown an association between DPP-4s and hospitalization for heart failure. However, it is not clear if the increased risk for heart failure seen in the trials is due to properties of the drugs, different patient characteristics between trials, or random error related to multiple hypothesis testing.

In a large cohort study, researchers compared rates of hospitalization for heart failure in new users of DPP-4s to rates in new users of other commonly-prescribed diabetes medications (pioglitazone, second-generation sulfonylureas, long-acting insulin products). The data did not show an increased risk for heart failure hospitalizations among DPP-4 users. The researchers suggest well-designed randomized trials to better understand the association between DPP-4s and heart failure.

Note: For an embargoed PDF, please contact Cara Graeff. To interview the lead author, Darren Toh, please contact Mary Wallan at or 617-509-2419.

3. Researchers review evidence on pharmacist-led care for chronic disease management
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Chronic disease management led by pharmacists can help patients achieve blood pressure, lipid, and glucose control goals. Whether it improves overall quality of care and clinical outcomes or is cost-effective is unclear. The evidence review is published in Annals of Internal Medicine .

Recently introduced legislation would establish pharmacists as health care providers and enable coverage of pharmacists' services through Medicare Part B in medically underserved communities. To determine the effectiveness and harms of pharmacist-led care for chronic disease, researchers reviewed 63 published studies involving 65 patient populations.

The data suggest that patients receiving pharmacist-led care were more likely to achieve target goals for blood pressure, cholesterol, and blood glucose compared with patients receiving usual care. Pharmacist-led care also increased the number of dosage of medications being received, but whether or not that was an indicator of better care quality was not clear. Patients in both groups used similar amounts of health care resources. The researchers suggest further research to determine patient outcomes under pharmacist-led care.

Note: For an embargoed PDF, please contact Cara Graeff. For an interview the lead author, Dr. Nancy Greer, please contact Ralph Heussner at or 612-467-3012.

Also in this issue:

Reporting of Sex Effects by Systematic Reviews on Interventions for Depression, Diabetes, and Chronic Pain Wei Duan-Porter, MD, PhD; Karen M. Goldstein, MD, MSPH; Jennifer R. McDuffie, PhD, MPH; Jaime M. Hughes, MPH, MSW; Megan E.B. Clowse, MD, MPH; Ruth S. Klap, PhD; Varsha Masilamani, MBBS; Nancy M. Allen LaPointe, PharmD, MHS; Avishek Nagi, MS; Jennifer M. Gierisch, PhD, MPH; and John W. Williams Jr., MD, MHSc

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