Cost-effectiveness of broadly neutralizing antibodies for infant HIV prophylaxis in settings with high HIV burdens: a simulation modeling study

Abstract

ABSTRACTIntroductionApproximately 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.MethodsWe 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 received1-dose,2-doses, orExtended(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).ResultsThe base case model projects that bNAb strategies targetingHIVEandALLinfants would prevent 7-26% and 10-42% additional pediatric HIV infections, respectively, compared to standard-of-care alone, ranging by dosing approach.HIVE-Extendedwould be cost-effective (cost-saving compared to standard-of-care) in Côte d’Ivoire and Zimbabwe;ALL-Extendedwould be cost-effective in South Africa (ICER: $882/YLS). BNAb strategies targetingHR-HIVEinfants would result in greater lifetime costs and smaller life expectancy gains thanHIVE-Extended. Throughout most bNAb efficacies and costs evaluated in sensitivity analyses, targetingHIVEinfants would be cost-effective in Côte d’Ivoire and Zimbabwe, and targetingALLinfants would be cost-effective in South Africa.DiscussionAdding 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.