A cost-effectiveness analysis of Molnupiravir and Paxlovid in three African countries

Abstract Objective To assess the cost-effectiveness of two COVID-19 oral antivirals (COAVs) Paxlovid and Molnupiravir compared to the standard of care, in Ghana, Rwanda and Zambia. Methods We modelled costs (2022 US$) and health outcomes in the acute phase of the COVID-19 disease from a public payer’s perspective in three unvaccinated target populations – (1) patients aged 65 years and above (elderly); (2) adult patients with at least one other underlying risk factors for disease severity; and (3) all adult patients. In addition, we conducted a series of sensitivity and scenario analyses. Results In elderly patients, Paxlovid was less costly and more effective (i.e., dominated) than standard of care in all three study countries. Molnupiravir dominated standard of care in Rwanda and Zambia and an incremental cost-effectiveness ratio (ICER) was estimated at US$1023.58 per disability-adjusted life year (DALY) averted in Ghana. In adults with other underlying risk factors, Paxlovid dominated in Rwanda and Zambia while Molnupiravir dominated in Rwanda. Neither Paxlovid nor Molnupiravir were cost-effective in the all-adult group in any country context. Incremental net monetary benefit for Paxlovid was consistently higher than for Molnupiravir. In COVID-19 vaccinated patients, Paxlovid was cost-effective for elderly patients in Zambia and Rwanda but not in Ghana. Key determinants of cost-effectiveness were COAV price, likelihood of early treatment initiation, and hospitalization rates. Conclusion In African settings similar to Zambia, Ghana or Rwanda, COAVs could be cost-effective in populations who are unvaccinated, and at high risk of progression to severe COVID-19. More evidence is needed to determine cost-effectiveness for patients that are unvaccinated but have previously been infected with COVID-19 and may have developed some immune protection. Key messages What is already known on this topic – Two COVID-19 oral antivirals (COAVs), Molnupiravir and Paxlovid have been shown to represent good value for money in high-income countries. However, there is a dearth of evidence on the cost-effectiveness of these drugs in African countries. What this study adds-This study finds that COAVs are likely to be cost-effective in populations who are unvaccinated and at high risk of progression to severe COVID-19. However, the probability of Molnupiravir being cost-effective was consistently lower than the probability of Paxlovid being cost-effective. Early treatment initiation, COAV price and baseline hospitalization rates had the largest impact on the cost-effectiveness of both COAVs in unvaccinated patients. More evidence is needed on the cost-effectiveness for patients who have previously been infected with COVID-19. How this study might affect research, practice, or policy – This study broadly supports African governments decisions to not procure substantial quantities of either COAV but is evidence that Paxlovid could be good value for money when treating very specific populations.