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Long\u2010acting pre\u2010exposure prophylaxis (LA PrEP) with injectable cabotegravir (CAB\u2010LA) or lenacapavir (LEN\u2010LA) is more effective at preventing HIV acquisition than oral PrEP. Our objective was to assess the potential clinical and economic impact of offering CAB\u2010LA or LEN\u2010LA to MSM and TGW with high vulnerability to HIV acquisition in Brazil and determine the maximum cost at which they would be cost\u2010effective.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      We used the CEPAC microsimulation model of HIV prevention and treatment to evaluate two strategies for MSM and TGW aged 18\u221249: (1)\n                      <jats:italic>SOC<\/jats:italic>\n                      : standard\u2010of\u2010care oral PrEP at current coverage, and (2)\n                      <jats:italic>SOC+LA<\/jats:italic>\n                      : offering oral and LA PrEP (either CAB\u2010LA or LEN\u2010LA). Input parameters are derived from Brazil\u2010based data from 2010 to 2024 and published studies: HIV incidence (%\/year, MSM: 3.4 [age 18\u221229 years], 1.1 [30\u221249 years]; TGW: 5.0 [18\u221229 years], 1.7 [30\u221249 years]), relative risk reduction, LA versus oral PrEP (66% [CAB\u2010LA]; 89% [LEN\u2010LA]), PrEP coverage (20% [oral PrEP]; 20% [LA PrEP]) and oral PrEP cost (programmatic+drug = $207\/year). Outcomes include lifetime HIV risk, life expectancy (LE) and incremental cost\u2010effectiveness ratio (ICER) of\n                      <jats:italic>SOC+LA<\/jats:italic>\n                      versus\n                      <jats:italic>SOC<\/jats:italic>\n                      in 2024 USD\/year of life saved (YLS). We identified the maximum LA PrEP cost with ICER below the established Brazilian willingness\u2010to\u2010pay threshold of $8740\/YLS.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Compared to\n                      <jats:italic>SOC, SOC+CAB\u2010LA<\/jats:italic>\n                      would decrease MSM lifetime HIV risk from 21.4% to 16.8%, increase undiscounted LE from 39.0 to 39.4 years. For TGW,\n                      <jats:italic>SOC+CAB\u2010<\/jats:italic>\n                      LA would decrease lifetime HIV risk from 29.5% to 23.4%, increase LE from 36.0 to 36.9 years. Results for\n                      <jats:italic>SOC+LEN\u2010LA<\/jats:italic>\n                      would be similar to\n                      <jats:italic>SOC+CAB\u2010LA<\/jats:italic>\n                      . SOC+LA would remain cost\u2010effective for MSM at cost below $710\/year for CAB\u2010LA and $740\/year for LEN\u2010LA. Findings are most sensitive to LA PrEP cost, HIV incidence, and whether and by how much LA PrEP increases coverage.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Offering LA PrEP with cabotegravir or lenacapavir in addition to oral PrEP for MSM and TGW in Brazil could markedly improve clinical outcomes and be cost\u2010effective at \u223c$700\/year. Cost agreements are critical to ensure these prevention options are accessible in high\u2010incidence settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/jia2.70116","type":"journal-article","created":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T06:01:22Z","timestamp":1778824882000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Long\u2010Acting PrEP for People With High Vulnerability to HIV Acquisition in Brazil: A Cost\u2010Effectiveness Analysis"],"prefix":"10.1002","volume":"29","author":[{"given":"Wanyi","family":"Chen","sequence":"first","affiliation":[{"name":"Medical Practice Evaluation Center, Massachusetts General Hospital  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9746-719X","authenticated-orcid":false,"given":"Paula M.","family":"Luz","sequence":"additional","affiliation":[{"name":"Instituto Nacional de Infectologia Evandro Chagas, Funda\u00e7\u00e3o Oswaldo Cruz  de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anjali","family":"Srinivasan","sequence":"additional","affiliation":[{"name":"Medical Practice Evaluation Center, Massachusetts General Hospital  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Beatriz","family":"Grinsztejn","sequence":"additional","affiliation":[{"name":"Instituto Nacional de Infectologia Evandro Chagas, Funda\u00e7\u00e3o Oswaldo Cruz  de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justine A.","family":"Scott","sequence":"additional","affiliation":[{"name":"Medical Practice Evaluation Center, Massachusetts General Hospital  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne M.","family":"Neilan","sequence":"additional","affiliation":[{"name":"Medical Practice Evaluation Center, Massachusetts General Hospital  Boston Massachusetts USA"},{"name":"Harvard Medical School  Boston Massachusetts USA"},{"name":"Division of Infectious Diseases, Massachusetts General Hospital  Boston Massachusetts USA"},{"name":"Center for AIDS Research, Harvard University  Cambridge Massachusetts USA"},{"name":"Division of General Academic Pediatrics, Massachusetts General Hospital  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Valdil\u00e9a G.","family":"Veloso","sequence":"additional","affiliation":[{"name":"Instituto Nacional de Infectologia Evandro Chagas, Funda\u00e7\u00e3o Oswaldo Cruz  de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caitlin M.","family":"Dugdale","sequence":"additional","affiliation":[{"name":"Medical Practice Evaluation Center, Massachusetts General Hospital  Boston Massachusetts USA"},{"name":"Harvard Medical School  Boston Massachusetts USA"},{"name":"Division of Infectious Diseases, Massachusetts General Hospital  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kenneth A.","family":"Freedberg","sequence":"additional","affiliation":[{"name":"Medical Practice Evaluation Center, Massachusetts General Hospital  Boston Massachusetts USA"},{"name":"Harvard Medical School  Boston Massachusetts USA"},{"name":"Division of Infectious Diseases, Massachusetts General Hospital  Boston Massachusetts USA"},{"name":"Center for AIDS Research, Harvard University  Cambridge Massachusetts USA"},{"name":"Division of General Internal Medicine Massachusetts General Hospital  Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,5,14]]},"reference":[{"key":"e_1_2_13_2_1","doi-asserted-by":"publisher","DOI":"10.1097\/MD.0000000000010602"},{"key":"e_1_2_13_3_1","unstructured":"\u201cunpby Location | Pivot Table | Data Portal \u201d Population Division Data Portal https:\/\/population.un.org\/dataportal\/data\/indicators\/46\/locations\/76\/start\/2023\/end\/2024\/table\/pivotbylocation?df=b911cc37\u2010d409\u2010496d\u20109c18\u201054e3adc2bc84."},{"key":"e_1_2_13_4_1","unstructured":"The Brazilian Institute of Geography and Statistics or Instituto Brasileiro de Geografia e Estat\u00edstica Pesquisa Nacional de Sa\u00fade [Internet] https:\/\/biblioteca.ibge.gov.br\/visualizacao\/livros\/liv101800.pdf."},{"key":"e_1_2_13_5_1","unstructured":"Available from:IBGE vai estimar tamanho da popula\u00e7\u00e3o trans e travesti no Brasil | Radioag\u00eancia Nacional[Internet]. 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