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Published on: October 31, 2010
Cost-effectiveness of broadly neutralizing antibody prophylaxis for HIV-exposed infants in sub-Saharan African
Caitlin M Dugdale1,2,3, Ogochukwu Ufio1, Christopher Alba1
1Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
Insights
Broadly neutralizing anti-HIV antibodies (bNAbs) offer a cost-effective strategy to prevent infant HIV transmission in sub-Saharan Africa. These interventions significantly reduce paediatric HIV incidence, proving valuable even with varying costs and efficacy.
Area of Science:
- Immunology
- Public Health
- Health Economics
Background:
- Infant HIV prophylaxis with broadly neutralizing anti-HIV antibodies (bNAbs) presents a potential long-acting strategy against vertical transmission.
- Sub-Saharan African settings face significant burdens of paediatric HIV, necessitating innovative prevention methods.
Purpose of the Study:
- To estimate the clinical impact and cost-effectiveness of hypothetical bNAb prophylaxis programs for HIV-exposed infants in Côte d'Ivoire, South Africa, and Zimbabwe.
- To compare different bNAb targeting strategies (high-risk vs. all exposed infants) and dosing regimens (1-dose, 2-doses, extended) against standard of care.
Main Methods:
- A cost-effectiveness analysis was performed using the CEPAC-Pediatric model, simulating infant cohorts from birth to death.
- Four prophylaxis approaches (standard of care, bNAbs at birth, bNAbs at birth and 3 months, extended bNAbs) were modeled for two target populations (high-risk HIV-exposed infants and all HIV-exposed infants).
- Key inputs included bNAb efficacy (60%/dose), duration (3 months/dose), and cost ($60/dose), with outcomes measured as paediatric HIV incidence and incremental cost-effectiveness ratios (ICERs).
Main Results:
- bNAb prophylaxis is projected to reduce absolute infant HIV incidence by 0.3-2.2% (9.6-34.9% relative reduction) across settings and strategies.
- The 'high-risk HIV-exposed infants - 1 dose' strategy was cost-saving compared to standard of care in all settings.
- Broadly neutralizing anti-HIV antibodies (bNAbs) demonstrated cost-effectiveness, with ICERs below the 50% GDP per capita threshold for the 'all HIV-exposed infants - extended' strategy in all three countries.
Conclusions:
- Broadly neutralizing anti-HIV antibody (bNAb) prophylaxis is a cost-effective intervention for reducing vertical HIV transmission in HIV-exposed children in sub-Saharan Africa.
- The findings remain robust across sensitivity analyses, supporting the implementation of bNAb strategies under current efficacy and cost estimates.
Introduction:
Infant HIV prophylaxis with broadly neutralizing anti-HIV antibodies (bNAbs) could provide long-acting protection against vertical transmission. We sought to estimate the potential clinical impact and cost-effectiveness of hypothetical bNAb prophylaxis programmes for children known to be HIV exposed at birth in three sub-Saharan African settings.
Methods:
We conducted a cost-effectiveness analysis using the CEPAC-Pediatric model, simulating cohorts of infants from birth through death in Côte d'Ivoire, South Africa and Zimbabwe. These settings were selected to reflect a broad range of HIV care cascade characteristics, antenatal HIV prevalence and budgetary constraints. We modelled strategies targeting bNAbs to only WHO-designated "high-risk" HIV-exposed infants (HR-HIVE) or to all HIV-exposed infants (HIVE). We compared four prophylaxis approaches within each target population: standard of care oral antiretroviral prophylaxis (SOC), and SOC plus bNAbs at birth (1-dose), at birth and 3 months (2-doses), or every 3 months throughout breastfeeding (Extended). Base-case model inputs included bNAb efficacy (60%/dose), effect duration (3 months/dose) and costs ($60/dose), based on published literature. Outcomes included paediatric HIV incidence and incremental cost-effectiveness ratios (ICERs) calculated from discounted life expectancy and lifetime HIV-related costs.
Results:
The model projects that bNAbs would reduce absolute infant HIV incidence by 0.3-2.2% (9.6-34.9% relative reduction), varying by country, prophylaxis approach and target population. In all three settings, HR-HIVE-1-dose would be cost-saving compared to SOC. Using a 50% GDP per capita ICER threshold, HIVE-Extended would be cost-effective in all three settings with ICERs of $497/YLS in Côte d'Ivoire, $464/YLS in South Africa and $455/YLS in Zimbabwe. In all three settings, bNAb strategies would remain cost-effective at costs up to $200/dose if efficacy is ≥30%. If the bNAb effect duration were reduced to 1 month, the cost-effective strategy would become HR-HIVE-1-dose in Côte d'Ivoire and Zimbabwe and HR-HIVE-2-doses in South Africa. Findings regarding the cost-effectiveness of bNAb implementation strategies remained robust in sensitivity analyses regarding breastfeeding duration, maternal engagement in postpartum care, early infant diagnosis uptake and antiretroviral treatment costs.
Conclusions:
At current efficacy and cost estimates, bNAb prophylaxis for HIV-exposed children in sub-Saharan African settings would be a cost-effective intervention to reduce vertical HIV transmission.
