Health Outcomes and Cost-effectiveness of Monoclonal SARS-CoV-2 Antibodies as Pre-exposure Prophylaxis
Authors: Popping Stephanie , Nichols Brooke E. , Appelman Brent , Biemond Jason J. , Vergouwe Magda , Rosendaal Frits R. , van der Valk Marc , de Bree Godelieve J. , Wiersinga W. Joost , Birnie Emma ,   TURN-COVID study group, Schinkel Michiel , Welkers Matthijs R.A. , Zaaijer Hans L. , Ittersum van Frans J. , Schim van der Loeff Maarten F. , Bomers Marije K. , Kersten Marie José , Hazenberg Mette D. , Heijmans Jarom , Kemper E. Marleen , de Boer Mark G.J. , Douma Renée A. , van den Berge Marcel , Hassing Robert-Jan , Amerlaan Heidi S.M. , van Vonderen Marit G.A. , Stalenhoef Janneke E. , Soetekouw Robin , van de Veerdonk Frank , Berrevoets Marvin A.H. , van Alphen Robbert J. , van Osch Frits , Wagenaar Jiri F.P. , van Marum Rob J. , Oude Lashof Astrid M.L. , van Nieuwkoop Cees 
Published: July 2023

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.