Economic evaluation of universal prenatal HIV screening compared with current 'at risk' policy in a very low prevalence country

Benefits and harms of antenatal and newborn screening programmes in health economic assessments: the VALENTIA systematic review and qualitative investigation

Background

Health economic assessments are used to determine whether the resources needed to generate net benefit from an antenatal or newborn screening programme, driven by multiple benefits and harms, are justifiable. It is not known what benefits and harms have been adopted by economic evaluations assessing these programmes and whether they omit benefits and harms considered important to relevant stakeholders.

Objectives

(1) To identify the benefits and harms adopted by health economic assessments in this area, and to assess how they have been measured and valued; (2) to identify attributes or relevance to stakeholders that ought to be considered in future economic assessments; and (3) to make recommendations about the benefits and harms that should be considered by these studies.

Design

Mixed methods combining systematic review and qualitative work.

Systematic review methods

We searched the published and grey literature from January 2000 to January 2021 using all major electronic databases. Economic evaluations of an antenatal or newborn screening programme in one or more Organisation for Economic Co-operation and Development countries were considered eligible. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist. We identified benefits and harms using an integrative descriptive analysis and constructed a thematic framework.

Qualitative methods

We conducted a meta-ethnography of the existing literature on newborn screening experiences, a secondary analysis of existing individual interviews related to antenatal or newborn screening or living with screened-for conditions, and a thematic analysis of primary data collected with stakeholders about their experiences with screening.

Results

The literature searches identified 52,244 articles and reports, and 336 unique studies were included. Thematic framework resulted in seven themes: (1) diagnosis of screened for condition, (2) life-years and health status adjustments, (3) treatment, (4) long-term costs, (5) overdiagnosis, (6) pregnancy loss and (7) spillover effects on family members. Diagnosis of screened-for condition (115, 47.5%), life-years and health status adjustments (90, 37.2%) and treatment (88, 36.4%) accounted for most of the benefits and harms evaluating antenatal screening. The same themes accounted for most of the benefits and harms included in studies assessing newborn screening. Long-term costs, overdiagnosis and spillover effects tended to be ignored. The wide-reaching family implications of screening were considered important to stakeholders. We observed good overlap between the thematic framework and the qualitative evidence.

Limitations

Dual data extraction within the systematic literature review was not feasible due to the large number of studies included. It was difficult to recruit healthcare professionals in the stakeholder's interviews.

Conclusions

There is no consistency in the selection of benefits and harms used in health economic assessments in this area, suggesting that additional methods guidance is needed. Our proposed thematic framework can be used to guide the development of future health economic assessments evaluating antenatal and newborn screening programmes.

Study registration

This study is registered as PROSPERO CRD42020165236.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127489) and is published in full in Health Technology Assessment; Vol. 28, No. 25. See the NIHR Funding and Awards website for further award information.

Does health economics research align with the disease burden in the Middle East and North Africa region? A systematic review of economic evaluation studies on public health interventions

Introduction

Economic evaluation studies demonstrate the value of money in health interventions and enhance the efficiency of the healthcare system. Therefore, this study reviews published economic evaluation studies of public health interventions from 26 Middle East and North Africa (MENA) countries and examines whether they addressed the region's major health problems.

Methods

PubMed and Scopus were utilized to search for relevant articles published up to June 26, 2021. The reviewers independently selected studies, extracted data, and assessed the quality of studies using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

Results

The search identified 61 studies. Approximately half (28 studies; 46%) were conducted in Israel and Iran. The main areas of interest for economic evaluation studies were infectious diseases (21 studies; 34%), cancers (13 studies; 21%), and genetic disorders (nine studies; 15%). Five (8%), 39 (64%), 16 (26%), and one (2%) studies were classified as excellent, high, average, and poor quality, respectively. The mean of CHEERS checklist items reported was 80.8% (SD 14%). Reporting the structure and justification of the selected model was missed in 21 studies (37%), while price and conversion rates and the analytical methods were missed in 21 studies (34%).

Conclusions

The quantity of economic evaluation studies on public health interventions in the MENA region remains low; however, the overall quality is high to excellent. There were obvious geographic gaps across countries regarding the number and quality of studies and gaps within countries concerning disease prioritization. The observed research output, however, did not reflect current and upcoming disease burden and risk factors trends in the MENA region.

HIV-1 infection among women in Israel, 2010-2018

INTRODUCTION

Although women comprise 33% of the HIV-1-carriers in Israel, they have not previously been considered a risk group requiring special attention. Immigration waves from countries in Africa and in East Europe may have changed the local landscape of women diagnosed with HIV-1. Here, we aimed to assess viral and demographic characteristics of HIV-1-positive women identified in Israel between 2010 and 2018.

METHODS

All > 16 year-old, HIV-1-infected women, diagnosed in Israel in 2010-2018, (n = 763) registered in the National HIV reference laboratory were included in this cross-sectional study. Demographic and clinical characteristics were extracted from the database. Viral subtypes and transmitted drug resistance mutations (TDRM) were determined in 337 (44.2%) randomly selected samples collected from treatment-naive women.

RESULTS

Median age at diagnosis was 38 years. Most (73.3%) women were immigrants from the former Soviet Union (FSU) (41.2%, 314) or sub-Saharan Africa (SSA) (32.2%, 246) and carried subtype A (79.7%) or C (90.3%), respectively. Only 11.4% (87) were Israeli-born women. Over the years, the prevalence of women from SSA decreased while that of women from FSU increased significantly (p < 0.001). The median CD4⁺ cell count was 263 cells/mm³, and higher (391 cells/mm³) in Israeli-born women. TDRM were identified in 10.4% of the tested samples; 1.8, 3 and 7.1% had protease inhibitors (PI), nucleotide reverse transcriptase inhibitors (NRTI) and non-nucleoside reverse transcriptase inhibitors (NNRTI) TDRM, respectively. The prevalence of women with NNRTI TDRM significantly increased from 4.9% in 2010-2012 to 13.3% in 2016-2018. Israeli-born women had the highest prevalence (16.3%) of NNRTI TDRM (p = 0.014). NRTI A62 (5.6%), NNRTI E138 and K103 (5.6 and 4.2%, respectively) were the most prominent mutated sites.

CONCLUSIONS

Most HIV-1-positive women diagnosed in Israel in 2010-2018 were immigrants, with the relative ratio of FSU immigrants increasing in recent years. The high proportion of women diagnosed with resistance mutations, particularly, the yearly increase in the frequency of NNRTI mutations, support the national policy of resistance testing at baseline.

HIV testing during pregnancy for prevention of mother-to-child transmission of HIV in Ethiopia

INTRODUCTION

HIV testing during pregnancy provides an entry point to prevention of mother-to-child transmission of HIV and to access treatment for HIV positive women. The study aimed to assess the uptake of HIV testing during pregnancy and associated factors among Ethiopian women.

METHODS

We analyzed the 2016 Ethiopian Demographic and Health Survey dataset. Women who gave birth within one year prior to the survey were included in the analysis. Uptake of HIV testing during pregnancy is defined as receiving HIV testing service during pregnancy and/or at the time of delivery and knew the test results. Adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs) were calculated by using step-wise backward logistic regression analyses to identify factors associated with HIV testing during pregnancy.

RESULTS

A total of 2114 women who were pregnant in the last one year prior to the survey were included in the analysis. Of these, only 35.1% were tested for HIV and received the test results during pregnancy. About one third of women who had antenatal care follow-up missed the opportunity to be tested for HIV. Compared to women who had no formal education, those who had primary level education (AOR = 1.55; 95% CI: 1.12-2.15), secondary level education (AOR = 2.56 95%CI: 1.36-3.82), or higher education (AOR = 3.95, 95%CI: 1.31-11.95) were more likely to be tested for HIV during pregnancy. Similarly, having awareness about mother-to-child transmission of HIV (AOR = 2.03, 95%CI: 1.48-2.78), and living in urban areas (AOR = 3.30, 95%CI: 1.39-7.85) were positively and independently associated with uptake of HIV during pregnancy. Women who have stigmatizing attitude towards HIV positive people were less likely to be tested for HIV (AOR = 0.57, 95%CI: 0.40-0.79).

CONCLUSION

Uptake of HIV testing during pregnancy is low. Missed opportunity among women who had antenatal care visits was very high. Integrating HIV testing with antenatal care services, improving HIV testing service quality and access are essential to increase uptake of HIV testing during pregnancy and reach the goal of eliminating MTCT.

Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis

Background

Screening is an important part of preventive medicine. Ideally, screening tools identify patients early enough to provide treatment and avoid or reduce symptoms and other consequences, improving health outcomes of the population at a reasonable cost. Cost-effectiveness analyses combine the expected benefits and costs of interventions and can be used to assess the value of screening tools.

Objective

This review seeks to evaluate the latest cost-effectiveness analyses on screening tools to identify the current challenges encountered and potential methods to overcome them.

Methods

A systematic literature search of EMBASE and MEDLINE identified cost-effectiveness analyses of screening tools published in 2017. Data extracted included the population, disease, screening tools, comparators, perspective, time horizon, discounting, and outcomes. Challenges and methodological suggestions were narratively synthesized.

Results

Four key categories were identified: screening pathways, pre-symptomatic disease, treatment outcomes, and non-health benefits. Not all studies included treatment outcomes; 15 studies (22%) did not include treatment following diagnosis. Quality-adjusted life years were used by 35 (51.4%) as the main outcome. Studies that undertook a societal perspective did not report non-health benefits and costs consistently. Two important challenges identified were (i) estimating the sojourn time, i.e., the time between when a patient can be identified by screening tests and when they would have been identified due to symptoms, and (ii) estimating the treatment effect and progression rates of patients identified early.

Conclusions

To capture all important costs and outcomes of a screening tool, screening pathways should be modeled including patient treatment. Also, false positive and false negative patients are likely to have important costs and consequences and should be included in the analysis. As these patients are difficult to identify in regular data sources, common treatment patterns should be used to determine how these patients are likely to be treated. It is important that assumptions are clearly indicated and that the consequences of these assumptions are tested in sensitivity analyses, particularly the assumptions of independence of consecutive tests and the level of patient and provider compliance to guidelines and sojourn times. As data is rarely available regarding the progression of undiagnosed patients, extrapolation from diagnosed patients may be necessary.

Missed opportunities for earlier diagnosis of HIV in patients who presented with advanced HIV disease: a retrospective cohort study

OBJECTIVE

To quantify and characterise missed opportunities for earlier HIV diagnosis in patients diagnosed with advanced HIV.

DESIGN

A retrospective observational cohort study.

SETTING

A central tertiary medical centre in Israel.

MEASURES

The proportion of patients with advanced HIV, the proportion of missed opportunities to diagnose them earlier, and the rate of clinical indicator diseases (CIDs) in those patients.

RESULTS

Between 2010 and 2015, 356 patients were diagnosed with HIV, 118 (33.4%) were diagnosed late, 57 (16%) with advanced HIV disease. Old age (OR=1.45 (95% CI 1.16 to 1.74)) and being heterosexual (OR=2.65 (95% CI 1.21 to 5.78)) were significant risk factors for being diagnosed late. All patients with advanced disease had at least one CID that did not lead to an HIV test in the 5 years prior to AIDS diagnosis. The median time between CID and AIDS diagnosis was 24 months (IQR 10-30). 60% of CIDs were missed by a general practitioner and 40% by a specialist.

CONCLUSIONS

Missed opportunities to early diagnosis of HIV occur in primary and secondary care. Lack of national guidelines, lack of knowledge regarding CIDs and communication barriers with patients may contribute to a late diagnosis of HIV.