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Cost-effectiveness of broadly neutralizing antibodies for HIV prophylaxis for all infants born in high-burden settings

Title
Cost-effectiveness of broadly neutralizing antibodies for HIV prophylaxis for all infants born in high-burden settings
Presenter
Caitlin M. Dugdale
Authors
C. Alba (1), S. Malhotra (2), S. Horsfall (1), M. Barnhart (3), K. Chapman (2), C.K. Cunningham (4,5), P. Fast (2,6), G.G. Fouda (7,8), K.A. Freedberg (1,9,10,11), L. Ghazaryan (3), V. Leroy (12), C. Mann (3), M.M. McCluskey (3), E.J. McFarland (13), V. Muturi-Kioi (14), S.R. Permar (15,16), D. Sok (2), L. Stranix-Chibanda (17), M.C. Weinstein (18), A.L. Ciaranello (1,9,10), C.M. Dugdale * (1,9,10)
Institutions
(1) Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, United States, (2) IAVI, Global Headquarters, New York, United States, (3) U.S. Agency for International Development (USAID), Office of HIV/AIDS, District of Columbia, United States, (4) University of California Irvine, Department of Pediatrics, Irvine, United States, (5) Children''s Hospital of Orange County, Department of Pediatrics, Orange, United States, (6) Stanford University School of Medicine, Pediatric Infectious Diseases, Palo Alto, United States, (7) Duke University Medical Center, Department of Pediatrics, Durham, United States, (8) Duke Human Vaccine Institute, Durham, United States, (9) Massachusetts General Hospital, Division of Infectious Diseases, Boston, United States, (10) Harvard Medical School, Boston, United States, (11) Massachusetts General Hospital, Division of General Internal Medicine, Boston, United States, (12) Inserm and Université Toulouse III, Centre d''Epidémiologie et de Recherche en santé des POPulations (CERPOP), Toulouse, France, (13) Children''s Hospital Colorado at University of Colorado Anschutz Medical Campus, Department of Pediatrics, Aurora, United States, (14) IAVI, Eastern Africa Regional Office, Nairobi, Kenya, (15) Weill Cornell Medicine, Department of Pediatrics, New York, United States, (16) New York-Presbyterian/Weill Cornell Medical Center, Department of Pediatrics, New York, United States, (17) University of Zimbabwe Faculty of Medicine and Health Sciences, Child and Adolescent Health Unit, Harare, Zimbabwe, (18) Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, United States

BACKGROUND: Approximately 150,000 infants acquire HIV annually despite maternal antiretroviral therapy scale-up. We evaluated the potential clinical impact, cost, and cost-effectiveness of offering anti-HIV broadly neutralizing antibody (bNAb) prophylaxis, once clinically approved, to infants in various high-burden settings.
METHODS: We simulated birth cohorts in Côte d''Ivoire, South Africa, and Zimbabwe using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) model. We modeled strategies offering a three-bNAb combination'in addition to standard-of-care prophylaxis, where WHO-recommended'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) regardless of known HIV exposure (ALL). Infants received one, two, or extended (every 3 months through 18 months) bNAb doses. We also modeled a strategy offering one birth bNAb dose to all infants plus extended dosing to infants with known exposure. Base-case model inputs, varied in sensitivity analyses, included bNAb efficacy (70%), efficacy duration/dosing interval (3 months), and cost ($20/dose). Outcomes included infant HIV infections, life expectancy, lifetime HIV-related costs, and incremental cost-effectiveness ratios (ICERs, in US$/year-of-life-saved, assuming a <50% GDP per capita cost-effectiveness threshold).
RESULTS: Under base-case assumptions, HIVE and ALL strategies would prevent 6-42% of infant HIV infections across settings (Figure 1A-C). Extended bNAbs for at least all known HIV-exposed infants would be cost-effective in all settings (Figure 1D-F). HR-HIVE strategies would result in greater lifetime costs and smaller life expectancy gains than HIVE strategies. At various bNAb costs and efficacies, HIVE strategies would be cost-effective in Côte d''Ivoire and Zimbabwe, and ALL strategies would be cost-effective in South Africa, partially driven by relatively higher maternal HIV prevalence (Figure 1D-F).


CONCLUSIONS: Adding long-acting bNAbs to current maternal-infant prophylaxis would be cost-effective over plausible cost and efficacy ranges, with the cost-effective target population varying by setting. Infant bNAb prophylaxis development and implementation should be prioritized in high-burden settings.