Journal Article

Optimizing infant HIV diagnosis with additional screening at immunization clinics in three sub‐Saharan African settings: a cost‐effectiveness analysis

Newell, Marie‐Louise, Phillips, Andrew, Myer, Landon, Dunning, Lorna, Abrams, Elaine, Revill, Paul, Dugdale, Caitlin, Soeteman, Djøra I, Frank, Simone, Collins, Intira J, Mushavi, Angela, Gandhi, Aditya R, Doherty, Meg, Vojnov, Lara, Weinstein, Milton C, Fassinou Ekouévi, Patricia, Freedberg, Kenneth A, Ciaranello, Andrea L, Penazzato, Martina

2021

Overview

Introduction Uptake of early infant HIV diagnosis (EID) varies widely across sub‐Saharan African settings. We evaluated the potential clinical impact and cost‐effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation. Methods Using the CEPAC‐Pediatric model, we compared two strategies for infants born in 2017 in Côte d’Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six‐week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six‐week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen‐and‐test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six‐week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen‐and‐test were 80%. Costs included NAT ( $24/infant), maternal screening ($ 10/mother–infant pair), ART ( $5 to 31/month) and HIV care ($ 15 to 190/month). Model outcomes included mother‐to‐child transmission of HIV (MTCT) among HIV‐exposed infants, and life expectancy (LE) and mean lifetime per‐person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost‐effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost‐effectiveness thresholds in each country: (1) the per‐capita GDP ( $1720/6380/2150) per year‐of‐life saved (YLS), and (2) the CEPAC‐generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second‐line ART; $ 520/500/580/YLS). Results With EID, projected six‐week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen‐and‐test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by$17 to 22/child (all children). The ICER of screen‐and‐test compared to EID was $ 1340/YLS (CI),$650/YLS (SA) and $ 670/YLS (Zimbabwe), below the per‐capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries. Conclusions Universal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV‐related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.

• Publisher: International AIDS Society,John Wiley & Sons, Inc,John Wiley and Sons Inc
• Subject: Acquired immune deficiency syndrome / Adult / Africa South of the Sahara / Age / AIDS / Antiretroviral agents / Antiretroviral drugs / Babies / Breastfeeding & lactation / Child / Child, Preschool / Community Health Centers / Computer simulation / Cost analysis / Cost-Benefit Analysis / Costs / Delivery of Health Care / Diagnosis / Diagnostic Tests, Routine - economics / Disease transmission / Diseases / Early Diagnosis / Early infant diagnosis / Female / HIV / HIV infection in children / HIV Infections - diagnosis / HIV Infections - drug therapy / HIV Infections - economics / HIV‐exposed infants / Human immunodeficiency virus / Humans / Immunization / Infant / Infants / Infants (Newborn) / Infections / Infectious Disease Transmission, Vertical - prevention & control / Life expectancy / Male / Mass Screening - economics / Medical diagnosis / Medical screening / Medical tests / Methods / Models, Biological / Monte Carlo simulation / Mothers / Nucleic acids / paediatric HIV testing / Pediatric research / Pediatrics / Perinatal infection / Pregnancy / Pregnancy Complications, Infectious / Prevention / prevention of mother‐to‐child HIV transmission / Risk factors / Statistics / Womens health