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Ciaranello AL, Park JE, Ramirez-Avila L, Freedberg KA, Walensky RP, Leroy V. Early infant HIV-1 diagnosis programs in resource-limited settings: opportunities for improved outcomes and more cost-effective interventions. BMC Med 2011; 9:59. [PMID: 21599888 PMCID: PMC3129310 DOI: 10.1186/1741-7015-9-59] [Citation(s) in RCA: 139] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 05/20/2011] [Indexed: 02/07/2023] Open
Abstract
Early infant diagnosis (EID) of HIV-1 infection confers substantial benefits to HIV-infected and HIV-uninfected infants, to their families, and to programs providing prevention of mother-to-child transmission (PMTCT) services, but has been challenging to implement in resource-limited settings. In order to correctly inform parents/caregivers of infant infection status and link HIV-infected infants to care and treatment, a 'cascade' of events must successfully occur. A frequently cited barrier to expansion of EID programs is the cost of the required laboratory assays. However, substantial implementation barriers, as well as personnel and infrastructure requirements, exist at each step in the cascade. In this update, we review challenges to uptake at each step in the EID cascade, highlighting that even with the highest reported levels of uptake, nearly half of HIV-infected infants may not complete the cascade successfully. We next synthesize the available literature about the costs and cost effectiveness of EID programs; identify areas for future research; and place these findings within the context of the benefits and challenges to EID implementation in resource-limited settings.
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Affiliation(s)
- Andrea L Ciaranello
- Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
| | - Ji-Eun Park
- Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lynn Ramirez-Avila
- Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
- Division of Infectious Diseases, Children's Hospital Boston, Boston, MA, USA
| | - Kenneth A Freedberg
- Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
- Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
- Center for AIDS Research, Harvard Medical School, Boston, MA, USA
| | - Rochelle P Walensky
- Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA
- Division of General Medicine, Massachusetts General Hospital, Boston, MA, USA
- Center for AIDS Research, Harvard Medical School, Boston, MA, USA
- Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Valeriane Leroy
- Inserm, Unité 897, Institut de Santé Publique, Epidémiologie et Développement (ISPED), Université Bordeaux Segalen, Bordeaux, France
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McCabe CJ, Goldie SJ, Fisman DN. The cost-effectiveness of directly observed highly-active antiretroviral therapy in the third trimester in HIV-infected pregnant women. PLoS One 2010; 5:e10154. [PMID: 20405011 PMCID: PMC2854147 DOI: 10.1371/journal.pone.0010154] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Accepted: 03/04/2010] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In HIV-infected pregnant women, viral suppression prevents mother-to-child HIV transmission. Directly observed highly-active antiretroviral therapy (HAART) enhances virological suppression, and could prevent transmission. Our objective was to project the effectiveness and cost-effectiveness of directly observed administration of antiretroviral drugs in pregnancy. METHODS AND FINDINGS A mathematical model was created to simulate cohorts of one million asymptomatic HIV-infected pregnant women on HAART, with women randomly assigned self-administered or directly observed antiretroviral therapy (DOT), or no HAART, in a series of Monte Carlo simulations. Our primary outcome was the quality-adjusted life expectancy in years (QALY) of infants born to HIV-infected women, with the rates of Caesarean section and HIV-transmission after DOT use as intermediate outcomes. Both self-administered HAART and DOT were associated with decreased costs and increased life-expectancy relative to no HAART. The use of DOT was associated with a relative risk of HIV transmission of 0.39 relative to conventional HAART; was highly cost-effective in the cohort as a whole (cost-utility ratio $14,233 per QALY); and was cost-saving in women whose viral loads on self-administered HAART would have exceeded 1000 copies/ml. Results were stable in wide-ranging sensitivity analyses, with directly observed therapy cost-saving or highly cost-effective in almost all cases. CONCLUSIONS Based on the best available data, programs that optimize adherence to HAART through direct observation in pregnancy have the potential to diminish mother-to-child HIV transmission in a highly cost-effective manner. Targeted use of DOT in pregnant women with high viral loads, who could otherwise receive self-administered HAART would be a cost-saving intervention. These projections should be tested with randomized clinical trials.
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Affiliation(s)
- Caitlin J. McCabe
- Child Health Evaluative Sciences, Research Institute of the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sue J. Goldie
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - David N. Fisman
- Child Health Evaluative Sciences, Research Institute of the Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Schittek H, Koopmans J, Ross LF. Pediatricians’ Attitudes About Screening Newborns for Infectious Diseases. Matern Child Health J 2008; 14:174-83. [DOI: 10.1007/s10995-008-0431-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2008] [Accepted: 11/12/2008] [Indexed: 11/25/2022]
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Hornberger J, Holodniy M, Robertus K, Winnike M, Gibson E, Verhulst E. A Systematic Review of Cost-Utility Analyses in HIV/AIDS: Implications for Public Policy. Med Decis Making 2007; 27:789-821. [DOI: 10.1177/0272989x07306112] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objectives . To determine whether gaps exist in published cost-utility analyses as measured by their coverage of topics addressed in current HIV guidelines from the Department of Health and Human Services (DHHS). Design . A systematic review of US-based cost-effectiveness analyses of HIV/AIDS prevention and management strategies, based on original, published research. Methods . Predefined criteria were used to identify all analyses pertaining to prevention and management of HIV/AIDS; information was collected on type of strategy, patient demographics, study perspective, quality of the study, effectiveness measures, costs, and cost-effectiveness ratios. Results . One hundred and six studies were identified; 62 described strategies for averting new HIV infections, and 44 dealt with managing persons who are HIV positive. The quality of studies was generally high, but gaps were found in all studies. Especially common were omissions in reporting data abstraction methodology and discussions of direction and magnitude of potential biases. Among the 22 most highly rated papers (score of 90 or higher), only 1 was cited in the guidelines, and 3 papers reported on interventions that were superseded by newer approaches. Using a $100,000 threshold, the guidelines usually endorsed interventions found to be cost-effective. Exceptions included recommending postexposure prophylaxis (PEP) for populations in which PEP is unlikely to be cost-effective and not recommending primary resistance testing in treatment-naive persons, although the intervention was reported to have a cost-effectiveness ratio of less than $50,000. Conclusions . Despite an abundant literature on the cost-utility of HIV/AIDS-targeted strategies, guidelines cite relatively few of these papers, and gaps exist regarding assessments of some strategies and special populations.
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Affiliation(s)
- John Hornberger
- The SPHERE Institute/Acumen, LLC, Burlingame, California, Department of Veterans Affairs, Palo Alto, California, Department of Medicine, Stanford University School of Medicine, Stanford, California,
| | - Mark Holodniy
- AIDS Research Center, VA Palo Alto Health Care System, Palo Alto, California, Division of Infectious Diseases & Geographic Medicine, Stanford University, Stanford, California, Veterans Health Administration, Public Health Strategic Health Care Group, Washington, DC
| | | | | | - Erin Gibson
- The SPHERE Institute/Acumen, LLC, Burlingame, California
| | - Eric Verhulst
- The SPHERE Institute/Acumen, LLC, Burlingame, California
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Creek TL, Sherman GG, Nkengasong J, Lu L, Finkbeiner T, Fowler MG, Rivadeneira E, Shaffer N. Infant human immunodeficiency virus diagnosis in resource-limited settings: issues, technologies, and country experiences. Am J Obstet Gynecol 2007; 197:S64-71. [PMID: 17825652 DOI: 10.1016/j.ajog.2007.03.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2006] [Revised: 02/16/2007] [Accepted: 03/01/2007] [Indexed: 11/18/2022]
Abstract
Diagnosing human immunodeficiency virus (HIV) infection in infants is difficult because maternal HIV antibodies cross the placenta, causing positive serologic tests in HIV-exposed infants for the first several months of life. Early definitive diagnosis of HIV requires virologic testing such as polymerase chain reaction (PCR), which is the diagnostic standard in resource-rich settings but has been too complex and expensive for widespread use in most countries with high HIV prevalence. Early PCR testing can help HIV-infected infants access treatment, provide psychosocial benefits for families of uninfected infants, and help programs for prevention of mother-to-child transmission of HIV monitor their effectiveness. HIV testing, including PCR, is increasingly available for infants in resource-limited settings, but there are many barriers and complex policy decisions that need to be addressed before universal early testing can become standard. This paper reviews challenges and progress in the field and suggests ways to facilitate early infant testing in resource-limited settings.
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Affiliation(s)
- Tracy L Creek
- Centers for Disease Control and Prevention/National Center for HIV, Hepatitis, STD, TB Prevention/Global AIDS Program, Atlanta, GA 30333, USA.
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Lorch SA, Cnaan A, Barnhart K. Cost-effectiveness of inhaled nitric oxide for the management of persistent pulmonary hypertension of the newborn. Pediatrics 2004; 114:417-26. [PMID: 15286225 DOI: 10.1542/peds.114.2.417] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator that has become part of the standard management for persistent pulmonary hypertension of the newborn (PPHN). This treatment modality, like many in neonatology, has not been well studied using quantitative economic techniques. The objective of this study was to evaluate the economic impact of adding iNO to the treatment protocol of PPHN for term infants from birth to the time of discharge from their initial hospitalization. METHODS We used decision analysis modeling from a societal perspective to obtain an incremental cost-effectiveness ratio. Outcome probabilities were taken from the medical literature and a cohort of 123 infants who were treated with PPHN at The Children's Hospital of Philadelphia between 1991 and 2002. Costs were estimated from daily resources used by these infants in 2001 dollars. Survival and quality-adjusted life years were used as effectiveness measures. One-way, threshold, and probabilistic sensitivity analyses were performed to assess the robustness of the base-case estimate. RESULTS The addition of iNO to the treatment regimen of PPHN increased the cost of treating an infant by an average of 1141 dollars, primarily from an increased number of mechanical ventilation days. Use of iNO led to 3.4% more lives saved and a 6% increase in the average utility gained per infant. The incremental cost-effectiveness ratio was 33,234 dollars per life saved and 19,022 dollars per quality-adjusted life year gained. The model was robust to changes in outcome probabilities, cost, and utility variables. Only 3.6% of the trials using probabilistic sensitivity analysis found iNO to be more expensive with a worse outcome than conventional therapy alone, whereas 35.7% of the trials found iNO to be cheaper and more effective than conventional treatment alone. CONCLUSIONS iNO is cost-effective but not cost-saving in treating infants with PPHN from a societal perspective. There are critical time points during an infant's hospitalization that could improve the efficiency and consequently the cost of care for this patient population.
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Affiliation(s)
- Scott A Lorch
- Department of Pediatrics, Center for Outcomes Research, Children's Hospital of Philadelphia, 3535 Market St, Ste 1029, Philadelphia, Pennsylvania 19104, USA.
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Affiliation(s)
- Douglas K Owens
- VA Health Care System (111A), 3801 Miranda Avenue, Palo Alto, CA 94304, USA.
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