Population effects of preventive and therapeutic HIV vaccines in early- and late-stage epidemics.

OBJECTIVE To evaluate the population effects of potential preventive and therapeutic vaccines in early- and late-stage epidemics in a population of homosexual men. METHODS An epidemic model was used that simulated the course of the epidemic for a population of homosexual men in San Francisco, California. Vaccine programs were evaluated by the number of cases of HIV averted, the effect on the prevalence of HIV, and by the gain in quality-adjusted life years (QALY) for the total population. RESULTS In the model, a preventive vaccine prevented 3877 cases of HIV infection during a 20-year period, reduced the projected prevalence of HIV infection from 12 to 7% in a late-stage epidemic, and gained 15,908 QALY. A therapeutic vaccine that did not affect the infectivity of vaccine recipients increased the number of cases of HIV infection by 210, resulted in a slight increase in the prevalence of HIV infection from 12 to 15% in a late-stage epidemic, and gained 8854 QALY. If therapeutic vaccines reduced infectivity, their use could produce net gains of QALY in the population that were similar to gains from the use of preventive vaccines. In an early-stage epidemic, the advantage of a preventive vaccine program relative to a therapeutic vaccine program was markedly enhanced. CONCLUSIONS Both preventive and therapeutic vaccine programs provided substantial benefit, but their relative merit depended on which outcome measures were assessed. Evaluation of HIV vaccine programs based solely on cases averted or on prevalence of HIV in the population underestimates the benefit associated with therapeutic vaccine programs. The effect of a therapeutic HIV vaccine on the epidemic outcomes depended markedly on whether the therapeutic vaccine reduced the infectivity of the vaccine recipient. The relative merits of preventive and therapeutic vaccines depend on the stage of the epidemic. Field vaccine trials should evaluate correlates of infectivity, such as HIV viral load. HIV vaccine implementation strategies should be tailored to the dynamics of the epidemic in specific populations.