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. 2023 Jul 3;6(7):e2321985.
doi: 10.1001/jamanetworkopen.2023.21985.

Health Outcomes and Cost-effectiveness of Monoclonal SARS-CoV-2 Antibodies as Pre-exposure Prophylaxis

Stephanie Popping  1   2 , Brooke E Nichols  3   4 , Brent Appelman  1 , Jason J Biemond  1 , Magda Vergouwe  1 , Frits R Rosendaal  5 , Marc van der Valk  6 , Godelieve J de Bree  7 , W Joost Wiersinga  1   7 , Emma Birnie  1 ; TURN-COVID study group
Collaborators, Affiliations

Health Outcomes and Cost-effectiveness of Monoclonal SARS-CoV-2 Antibodies as Pre-exposure Prophylaxis

Stephanie Popping et al. JAMA Netw Open. .

Abstract

Importance: Pre-exposure prophylaxis with neutralizing SARS-CoV-2 monoclonal antibodies (mAbs PrEP) prevents infection and reduces hospitalizations and the duration thereof for COVID-19 and death among high-risk individuals. However, reduced effectiveness due to a changing SARS-CoV-2 viral landscape and high drug prices remain substantial implementation barriers.

Objective: To assess the cost-effectiveness of mAbs PrEP as COVID-19 PrEP.

Design, setting, and participants: For this economic evaluation, a decision analytic model was developed and parameterized with health care outcome and utilization data from individuals with high risk for COVID-19. The SARS-CoV-2 infection probability, mAbs PrEP effectiveness, and drug pricing were varied. All costs were collected from a third-party payer perspective. Data were analyzed from September 2021 to December 2022.

Main outcomes and measures: Health care outcomes including new SARS-CoV-2 infections, hospitalization, and deaths. The cost per death averted and cost-effectiveness ratios using a threshold for prevention interventions of $22 000 or less per quality-adjusted life year (QALY) gained.

Results: The clinical cohort consisted of 636 individuals with COVID-19 (mean [SD] age 63 [18] years; 341 [54%] male). Most individuals were at high risk for severe COVID-19, including 137 (21%) with a body mass index of 30 or higher, 60 (9.4%) with hematological malignant neoplasm, 108 (17%) post-transplantation, and 152 (23.9%) who used immunosuppressive medication before COVID-19. Within the context of a high (18%) SARS-CoV-2 infection probability and low (25%) effectiveness the model calculated a short-term reduction of 42% ward admissions, 31% intensive care unit (ICU) admissions, and 34% deaths. Cost-saving scenarios were obtained with drug prices of $275 and 75% or higher effectiveness. With a 100% effectiveness mAbs PrEP can reduce ward admissions by 70%, ICU admissions by 97%, and deaths by 92%. Drug prices, however, need to reduce to $550 for cost-effectiveness ratios less than $22 000 per QALY gained per death averted and to $2200 for ratios between $22 000 and $88 000.

Conclusions and relevance: In this study, use of mAbs PrEP for preventing SARS-CoV-2 infections was cost-saving at the beginning of an epidemic wave (high infection probability) with 75% or higher effectiveness and drug price of $275. These results are timely and relevant for decision-makers involved in mAbs PrEP implementation. When newer mAbs PrEP combinations become available, guidance on implementation should be formulated ensuring a fast rollout. Nevertheless, advocacy for mAbs PrEP use and critical discussion on drug prices are necessary to ensuring cost-effectiveness for different epidemic settings.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr van der Valk reported receiving grants from ViiV paid to institution, grants from Gilead paid to institution, grants from mSd paid to institution, personal fees from ViiV paid to institution, personal fees from Gilead paid to institution, and personal fees from Merck, Sharp, and Dohme paid to institution outside the submitted work. Dr Wiersinga reported receiving grants from Netherlands Organization for Health Research and Development, grants from Netherlands Organization of Scientific Research (NWO) outside the submitted work, and an honorarium from GSK, Pfizer, Shionogi, and AstraZeneca; WJW received funding for Data Safety Monitoring Board membership, serving on the advisory board, and speaking at symposia from GSK, Pfizer, Shionogi, and AstraZeneca. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Cost Per Death Averted Varied Over Different Modeling Scenarios
The y-axis shows cost per death averted in dollars, and the x-axis the monoclonal antibodies pre-exposure prophylaxis (mAbs PrEP) effectiveness.
Figure 2.
Figure 2.. Short-term Cost-effectiveness Ratios Per Quality-Adjusted Life Year (QALY) Gained
The panels in the figure shows a different number of QALY gained per death averted representing different patient populations with underlying diseases and their life expectancy. CS indicates cost-saving ($<0).
Figure 3.
Figure 3.. One-way Sensitivity Analysis of the Cost-effectiveness Ratio Per Quality-Adjusted Life Year
We calculated the cost-effectiveness ratio per quality-adjusted life-year gained of no monoclonal antibodies pre-exposure prophylaxis (mAbs PrEP) vs 50% mAbs PrEP effectiveness, high mAbs PrEP price, and low SARS-CoV-2 infection probability as baseline comparator. The following key input parameters were independently varied: infection probability (0.01-0.2), effectiveness (10%-100%), drug price ($100-$5,000), admission probability (ward and ICU), mortality, and length of hospital stay (±50%). A medium number of quality-adjusted life-years (3.7) was used. The dotted line indicates the cost-effectiveness ratio per quality-adjusted life-year. The bars depict the variation in the cost-effectiveness ratio when parameters are independently varied. ICU indicates intensive care unit.
See this image and copyright information in PMC

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