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le Roux SM, Odayar J, Sutcliffe CG, Salvatore PP, de Broucker G, Dowdy D, McCann NC, Frank SC, Ciaranello AL, Myer L, Vojnov L. Cost-effectiveness of point-of-care versus centralised, laboratory-based nucleic acid testing for diagnosis of HIV in infants: a systematic review of modelling studies. Lancet HIV 2023; 10:e320-e331. [PMID: 37149292 PMCID: PMC10175481 DOI: 10.1016/s2352-3018(23)00029-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/31/2023] [Accepted: 02/03/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Point-of-care (POC) nucleic acid testing for diagnosis of HIV in infants facilitates earlier initiation of antiretroviral therapy (ART) than with centralised (standard-of-care, SOC) testing, but can be more expensive. We evaluated cost-effectiveness data from mathematical models comparing POC with SOC to provide global policy guidance. METHODS In this systematic review of modelling studies, we searched PubMed, MEDLINE, Embase, the National Health Service Economic Evaluation Database, Econlit, and conference abstracts, combining terms for "HIV" + "infant"/"early infant diagnosis" + "point-of-care" + "cost-effectiveness" + "mathematical models", without restrictions from database inception to July 15, 2022. We selected reports of mathematical cost-effectiveness models comparing POC with SOC for HIV diagnosis in infants younger than 18 months. Titles and abstracts were independently reviewed, with full-text review for qualifying articles. We extracted data on health and economic outcomes and incremental cost-effectiveness ratios (ICERs) for narrative synthesis. The primary outcomes of interest were ICERs (comparing POC with SOC) for ART initiation and survival of children living with HIV. FINDINGS Our search identified 75 records through database search. 13 duplicates were excluded, leaving 62 non-duplicate articles. 57 records were excluded and five were reviewed in full text. One article was excluded as it was not a modelling study, and four qualifying studies were included in the review. These four reports were from two mathematical models from two independent modelling groups. Two reports used the Johns Hopkins model to compare POC with SOC for repeat early infant diagnosis testing in the first 6 months in sub-Saharan Africa (first report, simulation of 25 000 children) and Zambia (second report, simulation of 7500 children). In the base scenario, POC versus SOC increased probability of ART initiation within 60 days of testing from 19% to 82% (ICER per additional ART initiation range US$430-1097; 9-month cost horizon) in the first report; and from 28% to 81% in the second ($23-1609, 5-year cost horizon). Two reports compared POC with SOC for testing at 6 weeks in Zimbabwe using the Cost-Effectiveness of Preventing AIDS Complications-Paediatric model (simulation of 30 million children; lifetime horizon). POC increased life expectancy and was considered cost-effective compared with SOC (ICER $711-850 per year of life saved in HIV-exposed children). Results were robust throughout sensitivity and scenario analyses. In most scenarios, platform cost-sharing (co-use with other programmes) resulted in POC being cost-saving compared with SOC. INTERPRETATION Four reports from two different models suggest that POC is a cost-effective and potentially cost-saving strategy for upscaling of early infant testing compared with SOC. FUNDING Bill & Melinda Gates Foundation, Unitaid, National Institute of Allergy and Infectious Diseases, National Institute of Child Health and Human Development, WHO, and Massachusetts General Hospital Research Scholars.
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Affiliation(s)
- Stanzi M le Roux
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa.
| | - Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Catherine G Sutcliffe
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Phillip P Salvatore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gatien de Broucker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nicole C McCann
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital Boston, MA, USA
| | - Simone C Frank
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital Boston, MA, USA
| | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital Boston, MA, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Lara Vojnov
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
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Katirayi L, Maphosa T, Kudiabor K, Kayira D, Gross J, Hrapcak S, Chamanga R, Nkhoma H, Puleni P, Maida A, Ahimbisibwe A, Woelk G. Acceptability and usability of a paediatric HIV screening tool in high-volume outpatient settings in Malawi, perspectives from caregivers and healthcare workers. BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2022-001713. [PMID: 36882230 PMCID: PMC10008159 DOI: 10.1136/bmjpo-2022-001713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/22/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Using an HIV pretest screening tool to identify children most at risk for HIV infection may be a more efficient and cost-effective approach to identify children living with HIV in resource-limited settings. These tools seek to reduce overtesting of children by increasing the positive predictive value while ensuring a high negative predictive value for those screened for HIV. METHODS This qualitative study in Malawi evaluated acceptability and usability of a modified version of the Zimbabwe HIV screening tool to identify children aged 2-14 years most-at-risk. The tool included additional questions about previous hospitalisations due to malaria and prior documented diagnoses. Sixteen interviews were conducted with expert clients (ECs), trained peer-supporters, which administered the screening tool and 12 interviews with biological and non-biological caregivers of screened children. All interviews were audiorecorded, transcribed and translated. Transcripts were analysed manually using a short-answer analysis, compiling responses for each question by study participant group. Summary documents were generated, identifying common and outlier perspectives. RESULTS The HIV paediatric screening tool was generally accepted by caregivers and ECs, with both groups seeing the benefit of the tool and promoting its use. The ECs who were primarily responsible for implementing the tool initially struggled with acceptance of the tool but started to accept it after additional training and mentorship was provided. Overall, caregivers accepted having their children tested for HIV, although non-biological caregivers expressed hesitancy in giving consent for HIV testing. ECs reported challenges with the ability for non-biological caregivers to answer some questions. CONCLUSION This study found general acceptance of paediatric screening tools in children in Malawi and identified some minor challenges that raise important considerations for tool implementation. These include the need for a thorough orientation of the tools for the healthcare workers and caregivers, appropriate space at the facility, and adequate staffing and commodities.
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Affiliation(s)
- Leila Katirayi
- Research Department, Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, USA
| | - Thulani Maphosa
- Research Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Kwashie Kudiabor
- Strategic Information and Evaluation Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Dumbani Kayira
- Care and Treatment Department, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Jessica Gross
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Susan Hrapcak
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rachel Chamanga
- Research Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Harrid Nkhoma
- Research Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Paul Puleni
- Programs Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Alice Maida
- Care and Treatment Department, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Allan Ahimbisibwe
- Programs Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Godfrey Woelk
- Research Department, Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, USA
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Sacks E, Katirayi L, Kaeberle B, Mafaune HW, Chadambuka A, Tachiwenyika E, Nyamundaya T, Cohn J, Mahomva A, Mushavi A. ‘The baby will have the right beginning’: a qualitative study on mother and health worker views on point-of-care HIV birth testing across 10 sites in Zimbabwe. BMC Pediatr 2022; 22:546. [PMID: 36104687 PMCID: PMC9472398 DOI: 10.1186/s12887-022-03601-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/07/2022] [Indexed: 11/29/2022] Open
Abstract
Background The survival of HIV-infected infants depends on early identification and initiation on effective treatment. HIV-exposed infants are tested at 6 weeks of age; however, testing for HIV sooner (e.g., shortly after birth) can identify in utero infection, which is associated with rapid progression. Infant early diagnostic virologic tests often have long turnaround times, reducing the utility of early testing. Point-of-care (POC) testing allows neonates born in health facilities to get results prior to discharge. This study aimed to understand the views of mothers and health workers regarding the use and acceptability of POC birth testing. Methods Beginning in 2018, Zimbabwe offered standard HIV testing at birth to high-risk HIV-exposed infants; as part of a pilot program, at 10 selected hospitals, POC birth testing (BT) was offered to every HIV-exposed infant. In order to understand experiences at the selected sites, 48 interviews were held: 23 with mothers and 25 with health workers, including 6 nurses-in-charge. Participants were purposively sampled across the participating sites. Interviews were held in English, Shona, or Ndebele, and transcribed in English. Line-by-line coding was carried out, and the constant comparison method of analysis was used to identify key themes for each respondent type. Results Findings were organized under four themes: challenges with BT, acceptability of BT, benefits of BT, and recommendations for BT programs. Overall, BT was well accepted by mothers and health workers because it encouraged mothers to better care for their uninfected newborns or initiate treatment more rapidly for infected infants. While the benefits were well understood, mothers felt there were some challenges, namely that they should be informed in advance about testing procedures and tested in a more private setting. Mothers and HCWs also recommended improving awareness of BT, both among health care workers and in the community in general, as well as ensuring that facilities are well-stocked with supplies and can deliver results in a timely way before scaling up programs. Conclusions Mothers and health workers strongly support implementation and expansion of birth testing programs due to the benefits for newborns. The challenges noted should be taken as planning guidance, rather than reasons to delay or discontinue birth testing programs. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03601-x.
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Tembo T, Dale H, Muttau N, Itoh M, Williamson D, Mwamba C, Manasyan A, Beard RS, Cox MH, Herce ME. “Testing Can Be Done Anywhere”: A Qualitative Assessment of Targeted Community-Based Point-of-Care Early Infant Diagnosis of HIV in Lusaka, Zambia. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00723. [PMID: 36332072 PMCID: PMC9242615 DOI: 10.9745/ghsp-d-21-00723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 04/26/2022] [Indexed: 11/23/2022]
Abstract
Community-based point-of-care testing is an acceptable, appropriate, and feasible strategy for improving access to HIV diagnostic services for high-risk HIV-exposed infants. Introduction: Delayed HIV diagnosis in HIV-exposed infants (HEIs) results in missed opportunities for early antiretroviral therapy (ART), causing significant morbidity and mortality. Early infant diagnosis (EID) depends on the availability of accessible and reliable testing services. We explored the acceptability, appropriateness, and feasibility of deploying a targeted community-based point-of-care (POC) EID testing model (i.e., “community POC model”) to reach high-risk mother-infant pairs (MIPs) in Lusaka, Zambia. Methods: We conducted in-depth interviews with a purposive sample of health care workers, study staff, and caregivers in high-risk MIPs at 6 health facilities included in a larger implementation research study evaluating the community POC model. We defined “high-risk MIPs” as mothers who did not receive antenatal testing or an attended delivery or infants who missed EID testing milestones. Interviews were audio-recorded, translated, and transcribed verbatim in English. Content and thematic analysis were done using NVivo 10 software. Results: Health care workers (n=20) and study staff (n=12) who implemented the community POC model noted that the portability and on-screen prompts of the POC platform made it mobile and easy to use, but maintenance and supply chain management were key to field operations. Respondents also felt that the community POC model reached more infants who had never had EID testing, allowing them to find infants with HIV infection and immediately initiate them on ART. Caregivers (n=22) found the community POC model acceptable, provided that privacy could be ensured because the service was convenient and delivered close to home. Conclusion: We demonstrate the acceptability, appropriateness, and feasibility of implementing the community POC model in Zambia, while identifying potential challenges related to client privacy and platform field operations. The community POC model may represent a promising strategy to further facilitate active HIV case finding and linkage to ART for children with undiagnosed HIV infection in the community.
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Affiliation(s)
- Tannia Tembo
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.
| | - Helen Dale
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nobutu Muttau
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Megumi Itoh
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Albert Manasyan
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - R Suzanne Beard
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Michael E Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Sacks E, Khumalo P, Tsabedze B, Montgomery W, Mthethwa N, Nhlabatsi B, Masuku T, Cohn J, Chouraya C. "The right time is just after birth": acceptability of point-of-care birth testing in Eswatini: qualitative results from infant caregivers, health care workers, and policymakers. BMC Pediatr 2020; 20:347. [PMID: 32669131 PMCID: PMC7362515 DOI: 10.1186/s12887-020-02242-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/08/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Testing for HIV at birth has the potential to identify infants infected in utero, and allows for the possibility of beginning treatment immediately after birth; point of care (POC) testing allows rapid return of results and faster initiation on treatment for positive infants. Eswatini piloted birth testing in three public maternities for over 2 years. METHODS In order to assess the acceptability of POC birth testing in the pilot sites in Eswatini, interviews were held with caregivers of HIV-exposed infants who were offered birth testing (N = 28), health care workers (N = 14), and policymakers (N = 10). Participants were purposively sampled. Interviews were held in English or SiSwati, and transcribed in English. Transcripts were coded by line, and content analysis and constant comparison were used to identify key themes for each respondent type. RESULTS Responses were categorized into: knowledge, experience, opinions, barriers and challenges, facilitators, and suggestions to improve POC birth testing. Preliminary findings reveal that point of care birth testing has been very well received but challenges were raised. Most caregivers appreciated testing the newborns at birth and getting results quickly, since it reduced anxiety of waiting for several weeks. However, having a favorable experience with testing was linked to having supportive and informed family members and receiving a negative result. Caregivers did not fully understand the need for blood draws as opposed to tests with saliva, and expressed the fears of seeing their newborns in pain. They were specifically grateful for supportive nursing staff who respected their confidentiality. Health care workers expressed strong support for the program but commented on the high demand for testing, increased workload, difficulty with errors in the testing machine itself, and struggles to implement the program without sufficient staffing, especially on evenings and weekends when phlebotomists were not available. Policymakers noted that there have been challenges within the program of losing mothers to follow up after they leave hospital, and recommended stronger linkages to community groups. CONCLUSIONS There is strong support for scale-up of POC birth testing, but countries should consider ways to optimize staffing and manage demand.
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Affiliation(s)
- Emma Sacks
- Department of Global Health, George Washington University School of Public Health, 950 New Hampshire Ave, NW, Washington, DC, 20052, USA.
| | | | | | - William Montgomery
- Department of Global Health, George Washington University School of Public Health, 950 New Hampshire Ave, NW, Washington, DC, 20052, USA
| | | | | | - Thembie Masuku
- Elizabeth Glaser Pediatric AIDS Foundation, Mbabane, Eswatini
| | - Jennifer Cohn
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
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