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

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 ### Competing Interest Statement Javier Guzman participated in a paid training session and a lecture sponsored by the pharmaceutical industry in 2021 ### Funding Statement This work was created as part of the International Decision Support Initiative (IDSI), funded by the Bill and Melinda Gates Foundation (grant number: OPP1202541). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript