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Cost-effectiveness of broadly neutralizing antibodies for infant HIV prophylaxis in settings with high HIV burdens: a
Christopher Alba1, Shelly Malhotra2, Stephanie Horsfall1
1Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, United States.
Insights
Long-acting broadly neutralizing antibody (bNAb) prophylaxis can prevent additional pediatric HIV infections. Cost-effectiveness varies by setting, with targeted infant groups showing the most promise for preventing infections and saving lives.
Area of Science:
- Pediatric infectious diseases
- Immunology and virology
- Health economics and outcomes research
Background:
- Despite global efforts, approximately 130,000 infants contract HIV annually.
- Maternal antiretroviral therapy scale-up has not eliminated new pediatric HIV infections.
- There is a need for novel prophylactic strategies to protect infants from HIV.
Approach:
- A Cost-Effectiveness of Preventing AIDS Complications-Pediatric (CEPAC-P) model simulated infants in Côte d'Ivoire, South Africa, and Zimbabwe.
- Evaluated strategies included offering a three-bNAb combination alongside standard-of-care oral prophylaxis.
- Modeled different infant targeting groups (high-risk, known exposure, all infants) and dosing schedules (1-dose, 2-doses, extended).
Key Points:
- bNAb strategies targeting infants with known HIV exposure (HIVE) and all infants (ALL) could prevent 7-26% and 10-42% more pediatric HIV infections, respectively.
- The 'HIVE-Extended' bNAb regimen was projected to be cost-effective in Côte d'Ivoire and Zimbabwe.
- The 'ALL-Extended' bNAb regimen was projected to be cost-effective in South Africa (ICER: $882/YLS).
Conclusions:
- Adding long-acting bNAbs to standard-of-care prophylaxis is a potentially cost-effective strategy for preventing pediatric HIV.
- Optimal target populations and dosing strategies for bNAb prophylaxis vary by geographic setting.
- Cost-effectiveness is influenced by factors such as maternal HIV prevalence and postpartum incidence.
Introduction:
Approximately 130 000 infants acquire HIV annually despite global maternal antiretroviral therapy scale-up. We evaluated the potential clinical impact and cost-effectiveness of offering long-acting, anti-HIV broadly neutralizing antibody (bNAb) prophylaxis to infants in three distinct settings.
Methods:
We simulated infants in Côte d'Ivoire, South Africa, and Zimbabwe using the Cost-Effectiveness of Preventing AIDS Complications-Pediatric (CEPAC-P) model. We modeled strategies offering a three-bNAb combination in addition to WHO-recommended standard-of-care oral prophylaxis to infants: a) with known, WHO-defined high-risk HIV exposure at birth (HR-HIVE); b) with known HIV exposure at birth (HIVE); or c) with or without known HIV exposure (ALL). Modeled infants received 1-dose, 2-doses, or Extended (every 3 months through 18 months) bNAb dosing. Base case model inputs included 70% bNAb efficacy (sensitivity analysis range: 10-100%), 3-month efficacy duration/dosing interval (1-6 months), and $20/dose cost ($5-$100/dose). Outcomes included pediatric HIV infections, life expectancy, lifetime HIV-related costs, and incremental cost-effectiveness ratios (ICERs, in US$/year-of-life-saved [YLS], assuming a ≤50% GDP per capita cost-effectiveness threshold).
Results:
The base case model projects that bNAb strategies targeting HIVE and ALL infants would prevent 7-26% and 10-42% additional pediatric HIV infections, respectively, compared to standard-of-care alone, ranging by dosing approach. HIVE-Extended would be cost-effective (cost-saving compared to standard-of-care) in Côte d'Ivoire and Zimbabwe; ALL-Extended would be cost-effective in South Africa (ICER: $882/YLS). BNAb strategies targeting HR-HIVE infants would result in greater lifetime costs and smaller life expectancy gains than HIVE-Extended. Throughout most bNAb efficacies and costs evaluated in sensitivity analyses, targeting HIVE infants would be cost-effective in Côte d'Ivoire and Zimbabwe, and targeting ALL infants would be cost-effective in South Africa.
Discussion:
Adding long-acting bNAbs to current standard-of-care prophylaxis would be cost-effective, assuming plausible efficacies and costs. The cost-effective target population would vary by setting, largely driven by maternal antenatal HIV prevalence and postpartum incidence.
