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


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.