Preventing HIV among the people at highest risk of acquiring it may cost far less than many public health agencies fear. A new economic analysis, published in Addiction Science & Clinical Practice, has produced the first detailed, bottom-up price tag for A.S.K.-PrEP, a community-based program in Los Angeles County that combines pre-exposure prophylaxis (PrEP) navigation with treatment support for substance use disorder among sexual and gender minorities. According to the study, launching the program requires roughly $25,958 in one-time start-up costs, sustaining it costs about $68,442 per year, and the incremental cost of delivering it ranges from just $16 to $104 per participant, depending on which services a client receives. The work, led by Danielle Ryan and Sean M. Murphy of Weill Cornell Medicine’s Department of Population Health Sciences, with Cathy J. Reback of the Friends Research Institute and UCLA and colleagues, set out to answer the question that quietly stalls countless evidence-based interventions: what would it actually cost a real clinic to run this program in the real world? For a population that accounts for the majority of the roughly 40,000 new HIV diagnoses in the United States each year, the answer is strikingly modest.
The backdrop is an epidemic that has become intensely concentrated. Nationwide, HIV prevalence among people aged 13 and older sits below 0.5 percent, but that average conceals staggering disparities. Among trans feminine women — transgender women along the trans feminine spectrum — estimated HIV prevalence ranges from 22 to 28 percent, the greatest burden of any population group. Among cisgender men who have sex with men, estimated prevalence is roughly 15 percent. PrEP medications, including daily oral regimens and newer long-acting injectables, are highly effective at blocking sexual transmission of the virus — but only if people start them, keep taking them, and remain engaged in monitoring, the three stages of the so-called PrEP Care Continuum where most attrition occurs. For people living with substance use disorder, every one of those steps is markedly harder. Clinical research has shown that stimulant use in particular undermines PrEP adherence among men who have sex with men, and substance use disorder is one of the most consistent barriers to progression along the entire continuum.
The economics of inaction are stark. Estimates cited in the study put the average lifetime cost of HIV-related medical care in the United States at about $368,000 per person — a figure that climbs to between $441,600 and $588,800 for people living with both HIV and a comorbid substance use disorder. The non-medical toll is heavier still. Substance use disorder is associated with reduced quality of life, elevated risk of overdose death, heavy reliance on high-cost emergency and inpatient care, participation in street economies, and incarceration; one economic analysis of opioid use disorder cited by the authors suggests these downstream consequences can add roughly $2 million per person over a lifetime. Against those figures, a combined prevention-and-treatment package costing four figures per client per year begins to look less like an expense and more like an investment. That logic animated the parent trial, funded by the National Institute on Drug Abuse, and frames the new analysis: before adopting a program, planners need to know precisely what it consumes.
A.S.K.-PrEP — short for Assistance Services Knowledge-PrEP — is built around a stepped-care philosophy. In the parent trial, HIV-negative sexual and gender minority adults aged 18 and older with a substance use disorder, all living in Los Angeles County, were randomly assigned in a 3:1 ratio to either the intervention or standard of care. Standard of care was deliberately minimal: an educational session about PrEP, an informational pamphlet, and a list of local clinics that prescribe it. The intervention arm instead received three months of client-centered PrEP navigation — five one-on-one sessions with a trained navigator — supplemented by weekly supportive text messages tailored to the experiences of sexual and gender minorities. Navigators tackled not only access to PrEP but the social determinants of health that sabotage it, from housing and food insecurity to transportation. At the three-month mark, participants were assessed on PrEP initiation, adherence, and use of their self-identified target substance. Those who had not responded — who had not started or adhered to PrEP, or kept using — were stepped up and re-randomized, this time 1:1, to contingency management alone or to contingency management plus three additional months of navigation and texting. The design, registered as clinical trial NCT05934877, generated three distinct intervention strategies whose costs could be compared head to head.
Contingency management, the escalation step, is among the most robustly evidence-backed behavioral treatments for stimulant use disorder, a condition for which no approved medication exists. The protocol is operationally simple but behaviorally sophisticated. Over 12 weeks, participants met with a behavioral technician three times per week to provide urine samples. Each sample testing negative for the participant’s target substance earned voucher points, starting at $2.50 and rising by $0.50 with every subsequent negative sample — an escalating schedule rooted in a core principle of behavioral science: reinforcement gains power as it grows. Three consecutive negative samples triggered an additional weekly bonus voucher worth $7.50, available throughout the 12 weeks. Vouchers, each valued at $1.00, could be redeemed at any time for goods and services that reinforce a prosocial, healthy lifestyle — clothing, groceries, a bicycle, help paying bills — but never for cigarettes, alcohol, or firearms. A positive sample dropped the participant back to the initial voucher value; three consecutive clean samples afterward restored their place in the escalation schedule, a design feature that keeps a single lapse from destroying hard-won momentum.
Quantifying the cost of all this required microcosting, the granular, bottom-up accounting method regarded as the gold standard in health economics. Rather than dividing a lump-sum budget by patient counts, the team applied activity-based costing: researchers visited the community-based organization delivering the program and conducted semi-structured interviews with everyone involved in daily operations, including the PrEP navigators, the clinical director, the clinical manager, and behavioral technicians cross-trained as phlebotomists. A follow-up virtual interview verified the initial findings and captured any changes in workflow. Every resource was then assigned a nationally representative price, expressed in 2024 dollars, to make the estimates portable to other regions. The researchers deliberately excluded PrEP medications themselves, since drug costs fall outside the intervention being evaluated. Resources were sorted into three categories — fixed start-up, time-dependent, and variable — and mapped onto two phases: a 12-month implementation phase from planning through steady state, and an open-ended sustainment phase aligned with the three-to-five-year budget cycles typical of health agencies. Crucially, the team estimated how many clients the program could actually serve with its resources — about eight per month — rather than the artificially constrained throughput of a research trial, so the figures describe a program a clinic could realistically operate.
The resulting ledger is unusually granular. Start-up costs of $25,958 were dominated by outreach — two behavioral technicians spending roughly 16 hours per month for a year distributing flyers and contacting partner organizations — plus one-time equipment purchases such as desk and cellular phones, tablets, a computer, and online marketing, and initial trainings covering HIV testing, counseling, and bloodborne pathogens. PrEP navigators completed about 80 hours of training in non-clinical support skills such as recovery planning and coping strategies, an eight-hour motivational interviewing course led by a clinical manager, and an eight-hour introduction to PrEP covering available medications and local access points. Time-dependent costs of $68,442 per year covered rent for a modest 130-square-foot office in Hollywood — deliberately positioned within the health service district carrying the county’s highest HIV incidence — along with monthly fees for the automated text-messaging platform, laboratory supplies for bloodwork and urine screening, phones, regular supervision meetings for navigators, biannual phlebotomy retraining, and annual HIV certification. Variable costs, which scale with each client served, averaged roughly $31,333 per year across strategies: $31,716 for A.S.K.-PrEP alone, $31,994 for A.S.K.-PrEP plus contingency management, and $30,271 for contingency management alone. A typical journey involves a 15-minute intake under standard of care, an initial one-hour navigation session with 30-minute follow-ups, a 10-minute introduction to contingency management, 15-minute visits three times weekly, and an average contingency management payout of $75 per participant. Staff also logged another 10 to 16 hours each month on scheduling, screening, and follow-up contacts. The first year of operation totals $125,325; each subsequent sustainment year runs about $99,366 — roughly $1,035 per client served.
Those numbers matter because the cost literature on HIV prevention is startlingly thin. As the authors note, a recent systematic review of the costs and cost-effectiveness of biomedical, non-surgical HIV prevention interventions found that most published studies were model-based economic evaluations; only nine collected primary data, and real-world delivery mechanisms were rarely examined. Against that sparse backdrop, this is, to the team’s knowledge, the first microcosting analysis of a client-centered PrEP navigation intervention designed specifically for sexual and gender minorities living with substance use disorder. One instructive benchmark comes from South Africa, where a demonstration project among female sex workers estimated PrEP delivery costs at roughly $168 per person-year after inflation — a figure the Los Angeles program’s per-client costs approach, while adding addiction treatment that most PrEP programs lack. Perhaps most consequential for practitioners is the counterintuitive pattern in per-participant costs: full navigation alone costs $104 per participant, navigation plus contingency management $73, and contingency management alone just $16, compared with $55 for standard of care. Because stepped-up clients have already completed intake and locator forms earlier in the program, later stages consume fewer resources — the stepped-care architecture is itself a cost-saving device.
To translate the findings into action, the team released a budget impact tool through CHERISH — the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV — freely accessible at CHERISHresearch.org, letting any prospective adopter plug in local wages, rents, and client volumes to see what the program would cost in their own setting. The authors caution that the analysis reflects a single urban site on the West Coast of the United States, shaped by Los Angeles wages and rents and by the local contours of the HIV and substance use syndemic, so other regions may face different figures. Even so, the broader implication is difficult to escape: uncertainty about cost, more often than cost itself, is what kills promising interventions before they spread. By showing that a program integrating HIV prevention with addiction treatment can be launched for about $26,000 and sustained for under $100,000 a year — with incremental per-participant costs measured in tens of dollars — the study converts a vague worry into a solvable budgeting problem. For the communities bearing the heaviest burden of the American HIV epidemic, that clarity may prove as consequential as the science behind the program itself.
Subject of Research: Microcosting analysis of the resources and costs required to implement and sustain the A.S.K.-PrEP intervention — client-centered PrEP navigation combined with contingency management for substance use disorder — among sexual and gender minority individuals.
Subject of Research: Medicine
Article Title: Microcosting the optimization of PrEP implementation among sexual and gender minority individuals with a substance use disorder
Article References: Ryan, D., Reback, C. J., Mata, R. P., Li, M., Jalali, A., Jeng, P. J., Benkeser, D., & Murphy, S. M. (2026). Microcosting the optimization of PrEP implementation among sexual and gender minority individuals with a substance use disorder. Addiction Science & Clinical Practice, 21(1), Article 43. https://doi.org/10.1186/s13722-026-00672-4
Image Credits: AI Generated
DOI: 10.1186/s13722-026-00672-4
Keywords: PrEP, HIV prevention, microcosting, substance use disorder, sexual and gender minorities, contingency management, budget impact analysis, PrEP navigation, stepped care, health economics
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Ophelia Keating. (August 30, 2026). Microcosting PrEP optimization for sexual and gender minorities with substance use disorders. Scienmag. https://scienmag.com/microcosting-prep-optimization-for-sexual-and-gender-minorities-with-substance-use-disorders/
Ophelia Keating. “Microcosting PrEP optimization for sexual and gender minorities with substance use disorders.” Scienmag, 30 August 2026, https://scienmag.com/microcosting-prep-optimization-for-sexual-and-gender-minorities-with-substance-use-disorders/. Accessed 30 August 2026.
Ophelia Keating. “Microcosting PrEP optimization for sexual and gender minorities with substance use disorders.” Scienmag. August 30, 2026. https://scienmag.com/microcosting-prep-optimization-for-sexual-and-gender-minorities-with-substance-use-disorders/
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