Cost-Effectiveness of Weekly Versus Monthly Malaria Chemoprevention Alternatives Among Children With Sickle Cell Anemia in Eastern and Southern Africa

OBJECTIVES: The current malaria chemoprvention regimes in Africa are either associated with increasing malaria resistance (sulphadoxine-pyrimethamine (SP)) or are difficult to adhere to (proguanil). We evaluate the cost-effectiveness of Dihydroartemisinin-piperaquine (DP) compared to SP for malaria chemoprevention among children with sickle cell aneamia (SCA) in Uganda and Malawi.

METHODS: This study was nested in a clinical trial (ClinicalTrials.gov (NCT04844099) of malaria chemoprevention alternatives with either weekly DP or monthly SP among children with SCA. A patient-simulated model (Markov) was developed to compute the incremental cost-effectiveness ratios (ICERs) expressed as costs per quality-adjusted life year (QALY) gained. The model utilised pooled primary data from the efficacy trials in Uganda and Malawi, implementation data from Uganda and secondary data. Cost data from a societal perspective was collected alongside the trial. Deterministic and probabilistic sensitivity analyses were performed to account for uncertainty.

RESULTS: The model predicts that DP is cost-effective compared to SP, with ICERs of USD 921 and USD 486 per QALY gained in Uganda and Malawi, respectively. The incremental effectiveness gain in the DP arm was 0.17 QALYs compared to SP, largely driven by reduced malaria incidence and hospitalisation. Probabilistic sensitivity analyses based on the Monte Carlo simulations suggest that DP is effective but more costly relative to the standard of care – SP in Uganda and Malawi. The most influential variables affecting the ICER were the disutility during hospitalisations and the cost of inpatient care.

CONCLUSIONS: DP has a high probability of being cost-effective in reducing clinical malaria than SP. However, in the main trial, SP has been associated with fewer episodes of non-malaria-related illnesses which may reflect malaria-independent effects. The findings support its use among children with sickle cell anaemia in Uganda, Malawi, and other sub-Saharan countries with similar malaria epidemiology and cost structures of health services.