Long-Acting Antiretroviral Therapy for Breastfeeding Women With HIV Experiencing Barriers to Adherence in Zimbabwe: Modeling Clinical Impact and Cost-effectiveness
Year: 2025
Type: article
Abstract: BACKGROUND: Long-acting antiretroviral therapy (LA-ART) may reduce adherence barriers for postpartum women with HIV (PPWH), reducing vertical transmission (VT) and improving pediatric life expectancy (pLE), but efficacy and drug costs are uncertain. METHODS: Using a microsimulation model, we simulated mother-infant dyads for two cohorts of PPWH engaged in care, receiving oral tenofovir/lamivudine/dolutegravir (TLD) in pregnancy, and facing adherence challenges in Zimbabwe: mothers without (NVS) and with (VS) viral suppression at delivery. We modeled two post-delivery strategies: standard of care (SOC: TLD continuation) or LA-ART (switching to LA-cabotegravir/rilpivirine [CAB/RPV]). Key inputs included: 6-month-postpartum viral suppression (LA-ART: NVS = 85%/VS = 90%; SOC: NVS = 63%/VS = 78%), ART costs/year (CAB/RPV=$144/TLD=$43.20), and VT risk (0.06%-0.89%/month, range by maternal RNA). Outcomes include VT, pLE, costs (maternal ART in breastfeeding plus pediatric HIV-related lifetime care), and incremental cost-effectiveness ratios (ICERs, $/year-of-life-saved [YLS]; cost-effective: ICER≤$800/YLS [0.5× Zimbabwe GDP]. RESULTS: LA-ART would reduce VT compared with SOC (NVS: from 7.49% to 6.58%/VS: from 4.17% to 3.80%), averting ∼160 infections/year in Zimbabwe. For NVS, LA-ART would improve pLE (SOC = 66.08y, LA-ART = 66.40y) at nearly equal cost (SOC = $764/child, LA-ART = $763/child); LA-ART would not be cost-effective if CAB/RPV cost >$228/year or 6-month suppression were <74%. For VS, LA-ART would lead to higher pLE and costs (67.52y, $555/child) than SOC (67.40y, $445/child), with ICER=$2449/YLS; LA-ART would become cost-effective if CAB/RPV cost ≤$84/year. CONCLUSIONS: LA-ART for breastfeeding women experiencing adherence challenges could reduce infant infections. If efficacies and costs are confirmed, LA-ART for NVS women would improve outcomes and be minimally cost-saving; for VS women, LA-ART would be cost-effective in Zimbabwe at costs ≤$84/year.
Authors: Sujata E Tewari, Risa Hoffman, Shahin Lockman, Clare F Flanagan, Karen A Webb, Stephanie Horsfall, Anesu Chimwaza, Caitlin M Dugdale, Judith Currier, Efison Dhodho, Anne M Neilan, Kenneth Masiye, Aadia Rana, Angela Mushavi, Florence Ebem, Kudakwashe C Takarinda, Sophie Desmonde, Kenneth A Freedberg, Andrea L Ciaranello
Institutions: Massachusetts General Hospital, University of California, Los Angeles, Brigham and Women's Hospital, Harvard University, Botswana Harvard AIDS Institute Partnership, Ministry of Health and Child Welfare, University of Alabama at Birmingham, UAB Medicine, Inserm, Université de Toulouse, Centre d'Epidémiologie et de Recherche en santé des POPulations de Toulouse
Language: English
Subfield: Infectious Diseases
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,763
OpenAlex ID: W4416890317