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Published on: September 6, 2019
Cost-effectiveness of broadly neutralizing antibodies for HIV prophylaxis for infants born in settings with high HIV
Christopher Alba1, Shelly Malhotra2, Stephanie Horsfall1
1Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
Insights
Long-acting broadly neutralizing antibody (bNAb) prophylaxis can significantly reduce pediatric HIV infections. The most cost-effective infant HIV prevention strategy varies by country, depending on local HIV prevalence.
Area of Science:
- Pediatric infectious diseases
- Immunology
- Health economics
Background:
- Despite global efforts, approximately 130,000 infants contract HIV annually.
- Maternal antiretroviral therapy scale-up has not eliminated new pediatric HIV infections.
Purpose of the Study:
- To evaluate the clinical impact and cost-effectiveness of long-acting anti-HIV broadly neutralizing antibody (bNAb) prophylaxis for infants.
- To compare different dosing strategies and target populations for bNAb interventions.
Main Methods:
- The Cost-Effectiveness of Preventing AIDS Complications-Pediatric (CEPAC-P) model was used to simulate infants in Côte d'Ivoire, South Africa, and Zimbabwe.
- Strategies included adding a three-bNAb combination to standard-of-care oral prophylaxis for infants with known high-risk HIV exposure (HR-HIVE), known HIV exposure (HIVE), or all infants (ALL).
- Dosing varied (1-dose, 2-doses, Extended every 3 months through 18 months) with modeled efficacy, duration, and cost.
Main Results:
- bNAb strategies targeting HIVE and ALL infants could prevent an additional 7-26% and 10-42% of pediatric HIV infections, respectively.
- HIVE-Extended prophylaxis was cost-effective in Côte d'Ivoire and Zimbabwe; ALL-Extended was cost-effective in South Africa ($882/year-of-life-saved).
- Targeting HIVE infants was cost-effective in Côte d'Ivoire and Zimbabwe, while targeting ALL infants was cost-effective in South Africa across various sensitivity analyses.
Conclusions:
- Adding long-acting bNAbs to standard-of-care prophylaxis is a cost-effective strategy for preventing pediatric HIV infections.
- The optimal target population for bNAb interventions varies by setting, influenced by maternal HIV prevalence and postpartum incidence.
Background:
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).
Findings:
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.
Interpretation:
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.
