A cost-effectiveness analysis of Molnupiravir and Paxlovid for outpatient treatment of COVID-19 in three African countries.

Background: Two COVID-19 oral antivirals (COAVs), Molnupiravir and Paxlovid, have been shown to be cost-effective in high-income countries.

Aim: This study assesses the cost-effectiveness of Paxlovid and Molnupiravir, compared to usual care in three African countries.

Setting: The study was conducted using data from Ghana, Rwanda and Zambia.

Methods: We modelled costs (2022 United States dollars) and health outcomes in the acute phase of COVID-19 from a public payer's perspective in three unvaccinated target populations: (1) all adult patients, (2) patients aged 65 years and above (elderly), and (3) adult patients with other underlying risk factors for disease severity. We conducted pairwise and full incremental analyses.

Results: In the pairwise analysis, Paxlovid was less costly and more effective than usual care (i.e. dominated) in all three study countries for elderly patients, while in adults with other underlying risk factors, Paxlovid dominated in Rwanda and Zambia, and Molnupiravir dominated usual care in Rwanda. Neither Paxlovid nor Molnupiravir were cost-effective in the all-adult group in any country context. In the full incremental analysis, Paxlovid dominated both Molnupiravir and usual care in elderly patients (in all three countries) and in adults with other risk factors (in Rwanda and Zambia). Key determinants of cost-effectiveness were COAV price, likelihood of early treatment initiation, hospitalisation rates and vaccination status.

Conclusion: In African settings like Zambia, Ghana or Rwanda, Paxlovid could be cost-effective in unvaccinated populations and those at high risk of progression to severe COVID-19.

Contribution: This study broadly supports African governments decisions not to procure substantial quantities of COAV.