The cost-effectiveness of preventing mother-to-child transmission of HIV in low- and middle-income countries: systematic review

Modelling Methods of Economic Evaluations of HIV Testing Strategies in Sub-Saharan Africa: A Systematic Review

BACKGROUND AND OBJECTIVE

Economic evaluations, a decision-support tool for policy makers, will be crucial in planning and tailoring HIV prevention and treatment strategies especially in the wake of stalled and decreasing funding for the global HIV response. As HIV testing and treatment coverage increase, case identification becomes increasingly difficult and costly. Determining which subset of the population these strategies should be targeted to becomes of vital importance as well. Generating quality economic evidence begins with the validity of the modelling approach and the model structure employed. This study synthesises and critiques the reporting around modelling methodology of economic models in the evaluation of HIV testing strategies in sub-Saharan Africa.

METHODS

The following databases were searched from January 2000 to September 2020: MEDLINE, Embase, Scopus, EconLit and Global Health. Any model-based economic evaluation of a unique HIV testing strategy conducted in sub-Saharan Africa presenting a cost-effectiveness measure published from 2013 onwards was eligible. Data were extracted around three components: general study characteristics; economic evaluation design; and quality of model reporting using a novel tool developed for the purposes of this study.

RESULTS

A total of 21 studies were included; 10 cost-effectiveness analyses, 11 cost-utility analyses. All but one study was conducted in Eastern and Southern Africa. Modelling approaches for HIV testing strategies can be broadly characterised as static aggregate models (3/21), static individual models (6/21), dynamic aggregate models (5/21) and dynamic individual models (7/21). Adequate reporting around data handling was the highest of the three categories assessed (74%), and model validation, the lowest (45%). Limitations to model structure, justification of chosen time horizon and cycle length, and description of external model validation process were all adequately reported in less than 40% of studies. The predominant limitation of this review relates to the potential implications of the narrow inclusion criteria.

CONCLUSIONS

This review is the first to synthesise economic evaluations of HIV testing strategies in sub-Saharan Africa. The majority of models exhibited dynamic, stochastic and individual properties. Model reporting against the 13 criteria in our novel tool was mixed. Future model-based economic evaluations of HIV testing strategies would benefit from transparency around the choice of modelling approach, model structure, data handling procedures and model validation techniques.

Cost of improved test and treat strategies in Indonesia

OBJECTIVE

To estimate and compare the cost of improved test and treat strategies in Indonesia under HIV Awal (Early) Testing and Treatment Indonesia (HATI) implementation trial in community-based and hospital-based clinics.

DESIGN

The cost and outcome [i.e. CD4 + cell count] and viral load (VL) at the beginning of interventions and their change overtime) analysis of Simplifying ART Initiation (SAI), Community-based Organization and community-based ART Service (CBO), Motivational Interviewing (MI), Oral Fluid-based Testing (OFT), and Short Message Service (SMS) reminder in community-based and hospital-based clinics in 2018-2019.

METHOD

We estimated the total and unit costs per patient (under HATI implementation trial interventions) per year from societal perspective in various settings, including costs from patients' perspective for SAI and MI. We also analyzed the outcome variables (i.e. CD4 + cell count and VL at the beginning of each intervention, the change in CD4 + cell count and VL over time, and adherence rate).

RESULT

The unit cost per patient per year of SAI and SMS were lower at the community-based clinics, and more patients visited community-based clinics. The cost per patient visit from patient perspective for SAI and MI was mostly lower than 10% of the patients' household monthly expenditure. Average CD4 + cell count was higher and average VL was lower at the start of interventions at the community-based clinics, while average CD4 + cell count and VL changes and adherence rate were similar between the two types of clinics.

CONCLUSION

Community-based clinics hold the potential for scaling up the interventions as it costs less from societal perspective and showed better outcome improvement during the HATI implementation trial.

Costs of implementing community-based intervention for HIV testing in sub-Saharan Africa: a systematic review

BACKGROUND

Community-based interventions (CBIs) are interventions aimed at improving the well-being of people in a community. CBIs for HIV testing seek to increase the availability of testing services to populations that have been identified as at high risk by reaching them in homes, schools, or community centers. However, evidence for a detailed cost analysis of these community-based interventions in sub-Saharan Africa (SSA) is limited. We conducted a systematic review of the cost analysis of HIV testing interventions in SSA.

METHODS

Keyword search was conducted on SCOPUS, CINAHL, MEDLINE, PsycINFO, Web of Science, and Global Health databases. Three categories of key terms used were cost (implementation cost OR cost-effectiveness OR cost analysis OR cost-benefit OR marginal cost), intervention (HIV testing), and region (sub-Saharan Africa OR sub-Saharan Africa OR SSA). CBI studies were included if they primarily focused on HIV testing, was implemented in SSA, and used micro-costing or ingredients approach.

RESULTS

We identified 1533 citations. After screening, ten studies were included in the review: five from East Africa and five from Southern Africa. Two studies conducted cost-effectiveness analysis, and one study was a cost-utility analysis. The remainder seven studies were cost analyses. Four intervention types were identified: HIV self-testing (HIVST), home-based, mobile, and Provider Initiated Testing and Counseling. Commonly costed resources included personnel (n = 9), materials and equipment (n = 6), and training (n = 5). Cost outcomes reported included total intervention cost (n = 9), cost per HIV test (n = 9), cost per diagnosis (n = 5), and cost per linkage to care (n = 3). Overall, interventions were implemented at a higher cost than controls, with the largest cost difference with HIVST compared to facility-based testing.

CONCLUSION

To better inform policy, there is an urgent need to evaluate the costs associated with implementing CBIs in SSA. It is important for cost reports to be detailed, uniform, and informed by economic evaluation guidelines. This approach minimizes biases that may lead decision-makers to underestimate the resources required to scale up, sustain, or reproduce successful interventions in other settings. In an evolving field of implementation research, this review contributes to current resources on implementation cost studies.

Factors Associated With Success in Reducing HIV Mother-to-child Transmission in Sub-Saharan Africa: Interviews With Key Stakeholders

PURPOSE

A key global health challenge is the persistence of new pediatric HIV infections due to mother-to-child transmission (MCTC), particularly in sub-Saharan Africa. The purpose of this study was to identify the key strategies that some sub-Saharan African countries have used to successfully reduce new pediatric HIV infections.

METHODS

A qualitative study utilizing semistructured interviews with key stakeholders in 6 sub-Saharan African countries (Burundi, Malawi, Mozambique, South Africa, Swaziland, and Uganda) was conducted from September 2017 to September 2018. These stakeholders were situated in the National Department of Health or in international health-funding bodies relating to the provision of the HIV/AIDS implementation program in these countries. The countries were selected based on considerable success achieved with HIV treatment in pregnant women. Audio-recorded interviews were transcribed verbatim and thematic analysis was undertaken.

FINDINGS

In all, 6 interviews were conducted, and the mean time of the interviews was 62 min. There were similar numbers of men and women, and most were in the 35- to 45-year age group. Five in six were either a medical doctor or held a doctorate degree. Four in six had >10 years of experience working in the prevention of HIV (PMTCT). Four key strategies that contributed to significant reductions in pediatric HIV infection in the respective countries were identified: (1) committed political leadership; (2) support structures within the community; (3) innovation in service delivery; and (4) robust monitoring and evaluation systems. Stakeholders spoke about how their governments played a leading role in engagement with communities, and in the dissemination of services. Innovative service delivery comprising task-shifting initiatives and the integration of maternal, newborn, and child health and HIV PMCTC services played an important role in reducing the burdens experienced by women and health care workers, leading to improved health outcomes. Peer support also helped mothers to adhere to their treatment during and after pregnancy. The capacity of national programs to monitor and evaluate the PMTCT services and the importance of regular viral-load monitoring were highlighted by the stakeholders.

IMPLICATIONS

These strategies can be reviewed for possible implementation by other sub-Saharan African countries as possible means of reducing new pediatric HIV infections.

Programmes for the prevention of mother-to-child HIV infection transmission have made progress in Yunnan Province, China, from 2006 to 2015: a cost effective and cost-benefit evaluation

Background

Prevention of mother-to-child transmission (PMTCT) of HIV programmes have substantially reduced HIV infections among infants in Yunnan Province, China. We conducted a macro-level economic evaluation of Yunnan’s PMTCT programmes over the 10 years from 2006 to 2015 from a policymaker perspective.

Methods

The study methodology was in accordance with the guidelines from the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. We quantified the output from the Yunnan’s PMTCT programmes by estimating the number of paediatric HIV infections averted and the relative savings to both the health care system and society. The return-on-investment ratio (ROI) was calculated as the output (numerator) divided by the input (denominator).

Results

We have found that the US$ 49 million investment in Yunnan’s PMTCT programmes over the period from 2006 to 2015 averted an estimated 2725 new paediatric HIV infections and resulted in an estimated 134,008 QALY acquired. It saved an estimated US$ 0.5 billion in treatment expenditures for Yunnan’s healthcare system and nearly US$ 3.9 billion in productivity. The ROI was 88.4, meaning every US$ 1 invested brought about US$ 88.4 in benefits.

Conclusions

Our results support the ongoing investment in PMTCT programmes in Yunnan Province. The PMTCT strategy is a cost effective and cost-benefit strategy in the periods from 2006 to 2015. Despite higher investments in the future, the overall investment in the PMTCT programmes in Yunnan province could be offset by averting more paediatric infections.

Eliminating Mother-to-Child Transmission of HIV by 2030: 5 Strategies to Ensure Continued Progress

To keep up momentum in preventing mother-to-child transmission we propose: (1) advocating for greater political and financial commitment; (2) targeting high-risk populations such as adolescent girls and young women; (3) implementing novel service delivery models such as community treatment groups; (4) performing regular viral load monitoring during pregnancy and postpartum to ensure suppression before delivery and during breastfeeding; and (5) harnessing technology in monitoring and evaluation and HIV diagnostics.

Identifying priority technical and context-specific issues in improving the conduct, reporting and use of health economic evaluation in low- and middle-income countries

Background

The use of economic evaluation in healthcare policies and decision-making, which is limited in low- and middle-income countries (LMICs), might be promoted through the improvement of the conduct and reporting of studies. Although the literature indicates that there are many issues affecting the conduct, reporting and use of this evidence, it is unclear which factors should be prioritised in finding solutions. This study aims to identify the top priority issues that impede the conduct, reporting and use of economic evaluation as well as potential solutions as an input for future research topics by the international Decision Support Initiative and other movements.

Methods

A survey on issues regarding the conduct, reporting and use of economic evaluation as well as on potential solutions was conducted using an online questionnaire among researchers who have experience in conducting economic evaluations in LMICs. The respondents were requested to consider the list of issues provided, rank the most important ones and propose solutions. A scoring system was applied to derive the ranking of difficulties according to researchers’ responses. Issues were grouped into technical and context-specific difficulties and analysed separately as a whole and by region.

Results

Researchers considered the lack of quality local clinical data, poor reporting and insufficient data to conduct the analysis from the chosen perspective as the most important technical difficulties. On the other hand, the non-integration of economic evaluations into decision-making was considered the most important context-specific issue. Finally, context-specific issues were considered the larger barrier to the use of economic evaluation.

Conclusion

The technical issues that were considered most important were closely linked with the lack of an appropriately functioning information system as well as the capacity to generate essential contextual information (e.g. data and locally relevant utility values), especially when the methodology is complex. To overcome this, simpler approaches to collect data that yields information of comparable quality to more rigorous methods should be developed. The international community can play a major role through research on methodologies feasible for LMIC settings as well as in building research capacity in countries. Context-specific issues, which were recognised as larger barriers, should be improved in parallel.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0280-6) contains supplementary material, which is available to authorized users.

The Achilles' heel of prevention to mother-to-child transmission of HIV: Protocol implementation, uptake, and sustainability

The Joint United Nations Programme on HIV and AIDS proposed to reduce the vertical transmission of HIV from ∼72,200 to ∼8300 newly infected children by 2015 in South Africa (SA). However, cultural, infrastructural, and socio-economic barriers hinder the implementation of the prevention of mother-to-child transmission (PMTCT) protocol, and research on potential solutions to address these barriers in rural areas is particularly limited. This study sought to identify challenges and solutions to the implementation, uptake, and sustainability of the PMTCT protocol in rural SA. Forty-eight qualitative interviews, 12 focus groups discussions (n = 75), and one two-day workshop (n = 32 participants) were conducted with district directors, clinic leaders, staff, and patients from 12 rural clinics. The delivery and uptake of the PMTCT protocol was evaluated using the Consolidated Framework for Implementation Research (CFIR); 15 themes associated with challenges and solutions emerged. Intervention characteristics themes included PMTCT training and HIV serostatus disclosure. Outer-setting themes included facility space, health record management, and staff shortage; inner-setting themes included supply use and availability, staff-patient relationship, and transportation and scheduling. Themes related to characteristics of individuals included staff relationships, initial antenatal care visit, adherence, and culture and stigma. Implementation process themes included patient education, test results delivery, and male involvement. Significant gaps in care were identified in rural areas. Information obtained from participants using the CFIR framework provided valuable insights into solutions to barriers to PMTCT implementation. Continuously assessing and correcting PMTCT protocol implementation, uptake and sustainability appear merited to maximize HIV prevention.

Option B+ for the prevention of mother-to-child transmission of HIV infection in developing countries: a review of published cost-effectiveness analyses

OBJECTIVE

To review the published literature on the cost effectiveness of Option B+ (lifelong antiretroviral therapy) for preventing mother-to-child transmission (PMTCT) of HIV during pregnancy and breastfeeding to inform decision making in low- and middle-income countries.

METHODS

PubMed, Scopus, Google scholar and Medline were searched to identify studies of the cost effectiveness of the World Health Organization (WHO) treatment guidelines for PMTCT. Study quality was appraised using the consolidated health economic evaluation reporting standards checklist. Eligible studies were reviewed in detail to assess the relevance and impact of alternative evaluation frameworks, assumptions and input parameter values.

RESULTS

Five published cost effectiveness analyses of Option B+ for the PMTCT of HIV were identified. The reported cost-effectiveness of Option B+ varies substantially, with the results of different studies implying that Option B+ is dominant (lower costs, greater benefits), cost-effective (additional benefits at acceptable additional costs) or not cost-effective (additional benefits at unacceptable additional costs). This variation is due to significant differences in model structures and input parameter values. Structural differences were observed around the estimation of programme effects on infants, HIV-infected mothers and their HIV negative partners, over multiple pregnancies, as well assumptions regarding routine access to antiretroviral therapies. Significant differences in key input parameters were observed in transmission rates, intervention costs and effects and downstream cost savings.

CONCLUSIONS

Across five model-based cost-effectiveness analyses of strategies for the PMTCT of HIV, the most comprehensive analysis reported that option B+ is highly likely to be cost-effective. This evaluation may have been overly favourable towards option B+ with respect to some input parameter values, but potentially important additional benefits were omitted. Decision makers might be best advised to review this analysis, with a view to requesting additional analyses of the model to inform local funding decisions around alternative strategies for the PMTCT of HIV.

Economic Evaluation in Global Perspective: A Bibliometric Analysis of the Recent Literature

We present a bibliometric analysis of recently published full economic evaluations of health interventions and reflect critically on the implications of our findings for this growing field. We created a database drawing on 14 health, economic, and/or general literature databases for articles published between 1 January 2012 and 3 May 2014 and identified 2844 economic evaluations meeting our criteria. We present findings regarding the sensitivity, specificity, and added value of searches in the different databases. We examine the distribution of publications between countries, regions, and health areas studied and compare the relative volume of research with disease burden. We analyse authors' country and institutional affiliations, journals and journal type, language, and type of economic evaluation conducted. More than 1200 economic evaluations were published annually, of which 4% addressed low-income countries, 4% lower-middle-income countries, 14% upper-middle-income countries, and 83% high-income countries. Across country income levels, 53, 54, 86, and 100% of articles, respectively, included an author based in a country within the income level studied. Biomedical journals published 74% of economic evaluations. The volume of research across health areas correlates more closely with disease burden in high-income than in low-income and middle-income countries. Our findings provide an empirical basis for further study on methods, research prioritization, and capacity development in health economic evaluation.

Health technology assessment in low- and middle-income countries: a landscape assessment

Objectives

Health technology assessment (HTA) for a wide range of healthcare technologies is an essential component of well-functioning health systems. Knowledge of the use of HTA in low- and middle-income countries (LMICs) is limited.

Methods

We performed a survey of HTA in selected LMICs. We interviewed key stakeholders on the use, conduct and challenges of performing HTA in their countries. We performed mixed-methods analyses to identify, characterize and describe HTA and how it relates to gross domestic product and government effectiveness.

Key findings

Of the 19 countries selected for participation, stakeholders in 12 (63%) countries responded to the survey – Afghanistan, Bangladesh, Democratic Republic of Congo (DR Congo), Dominican Republic, Ethiopia, Jordan, Kenya, Namibia, Rwanda, South Africa, Swaziland and Vietnam. Eight countries surveyed have some form of informal HTA activity conducted by stakeholders including academia, industry, government and the World Health Organization. There is evidence of knowledge sharing with five countries using HTAs from their neighbouring countries or from more developed countries. We found no evidence of formal HTA performed through dedicated, independent bodies in the LMICs surveyed. There was some evidence that HTA was moderately related to GDP per capita and strongly related to degree of centralization (government effectiveness). Respondents identified resources, both financial and human, as challenges to conducting HTA.

Conclusions

Formal HTA appears to be non-existent or limited in the LMICs surveyed but some evidence of informal HTA exists. Efforts to formalize HTA and to use existing HTA evidence will improve the quality of regulatory, coverage, formulary and reimbursement decisions, and individual and public health.

Factors influencing acceptability of voluntary HIV testing among pregnant women in Gamboma, Republic of Congo

Background

This study was carried out to identify factors affecting the acceptability of voluntary HIV testing among pregnant women in a semi-rural city, Gamboma, Republic of Congo.

Methods

A cross-sectional study was conducted between January and September 2012. Pregnant women attending antenatal heath care at an integrated health center were enrolled after informed consent and followed through voluntary HIV testing.

Results

Among 136 participants, 98 women (72 %) accepted voluntary HIV testing after pre-test counseling. Women with basic education, those who cited blood transfusion as a mode of transmission and prevention of mother-to-child transmission (MTCT) were more likely to accept testing as well those informed about free HIV testing. Interestingly, pregnant women who had heard about HIV/AIDS from hospital setting were less likely to accept testing.

Conclusions

Our data indicate that increasing general education on HIV transmission/prevention modes is crucial for increasing acceptability of screening. Furthermore, HIV/AIDS knowledge disseminated to patients in hospital settings should be carefully monitored. Lastly, scaling-up MTCT services along with a better and larger community information, may address accessibility barriers observed in the present study.

Cost-effectiveness of a package of interventions for expedited antiretroviral therapy initiation during pregnancy in Cape Town, South Africa

Initiating antiretroviral therapy (ART) early in pregnancy is an important component of effective interventions to prevent the mother-to-child transmission of HIV (PMTCT). The rapid initiation of ART in pregnancy(RAP) program was a package of interventions to expedite ART initiation in pregnant women in Cape Town, South Africa. Retrospective cost-effectiveness, sensitivity and threshold analyses were conducted of the RAP program to determine the cost-utility thresholds for rapid initiation of ART in pregnancy. Costs were drawn from a detailed micro-costing of the program. The overall programmatic cost was US$880 per woman and the base case cost-effectiveness ratio was US$1,160 per quality-adjusted lifeyear (QALY) saved. In threshold analyses, the RAP program remained cost-effective if mother-to-child transmission was reduced by C0.33 %; if C1.76 QALY were saved with each averted perinatal infection; or if RAP-related costs were under US$4,020 per woman. The package of rapid initiation services was very cost-effective, as compared to standard services in this setting. Threshold analyses demonstrated that the intervention required minimal reductions in perinatal infections in order to be cost-effective. Interventions for the rapid initiation of ART in pregnancy hold considerable potential as a cost-effective use of limited resources for PMTCT in sub-Saharan Africa.

Risks and benefits of lifelong antiretroviral treatment for pregnant and breastfeeding women: a review of the evidence for the Option B+ approach

PURPOSE OF REVIEW

Considerable debate has emerged on whether Option B+ (B+), initiation of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, is the best approach to achieving elimination of mother-to-child-transmission. However, direct evidence and experience with B+ is limited. We review the current evidence informing the proposed benefits and potential risks of the B+ approach, distinguishing individual health concerns for mother and child from program delivery and public health issues.

RECENT FINDINGS

For mothers and infants, B+ may offer significant benefits for transmission prevention and maternal health. However, several studies raise concerns about the safety of ART exposure to fetuses and infants, as well as adherence challenges for pregnant and breastfeeding mothers. For program delivery and public health, B+ presents distinct advantages in terms of transmission prevention to uninfected partners and increased simplicity potentially improving program feasibility, access, uptake, and retention in care. Despite being more costly in the short-term, B+ will likely be cost effective over time.

SUMMARY

This review provides a detailed analysis of risks and benefits of B+. As national programs adopt this approach, it will be critical to carefully assess both short-term and long-term maternal and infant outcomes.

HPTN 071 (PopART): rationale and design of a cluster-randomised trial of the population impact of an HIV combination prevention intervention including universal testing and treatment - a study protocol for a cluster randomised trial

BACKGROUND

Effective interventions to reduce HIV incidence in sub-Saharan Africa are urgently needed. Mathematical modelling and the HIV Prevention Trials Network (HPTN) 052 trial results suggest that universal HIV testing combined with immediate antiretroviral treatment (ART) should substantially reduce incidence and may eliminate HIV as a public health problem. We describe the rationale and design of a trial to evaluate this hypothesis.

METHODS/DESIGN

A rigorously-designed trial of universal testing and treatment (UTT) interventions is needed because: i) it is unknown whether these interventions can be delivered to scale with adequate uptake; ii) there are many uncertainties in the models such that the population-level impact of these interventions is unknown; and ii) there are potential adverse effects including sexual risk disinhibition, HIV-related stigma, over-burdening of health systems, poor adherence, toxicity, and drug resistance.In the HPTN 071 (PopART) trial, 21 communities in Zambia and South Africa (total population 1.2 m) will be randomly allocated to three arms. Arm A will receive the full PopART combination HIV prevention package including annual home-based HIV testing, promotion of medical male circumcision for HIV-negative men, and offer of immediate ART for those testing HIV-positive; Arm B will receive the full package except that ART initiation will follow current national guidelines; Arm C will receive standard of care. A Population Cohort of 2,500 adults will be randomly selected in each community and followed for 3 years to measure the primary outcome of HIV incidence. Based on model projections, the trial will be well-powered to detect predicted effects on HIV incidence and secondary outcomes.

DISCUSSION

Trial results, combined with modelling and cost data, will provide short-term and long-term estimates of cost-effectiveness of UTT interventions. Importantly, the three-arm design will enable assessment of how much could be achieved by optimal delivery of current policies and the costs and benefits of extending this to UTT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01900977.

Financing structural interventions: going beyond HIV-only value for money assessments

OBJECTIVE

Structural interventions can reduce HIV vulnerability. However, HIV-specific budgeting, based on HIV-specific outcomes alone, could lead to the undervaluation of investments in such interventions and suboptimal resource allocation. We investigate this hypothesis by examining the consequences of alternative financing approaches.

METHODS

We compare three approaches for deciding whether to finance a structural intervention to keep adolescent girls in school in Malawi. In the first, HIV and non-HIV budget holders participate in a cross-sectoral cost-benefit analysis and fund the intervention if the benefits outweigh the costs. In the second silo approach, each budget holder considers the cost-effectiveness of the intervention in terms of their own objectives and funds the intervention on the basis of their sector-specific thresholds of what is cost-effective or not. In the third cofinancing approach, budget holders use cost-effectiveness analysis to determine how much they would be willing to contribute towards the intervention, provided that other sectors are willing to pay for the remaining costs. In addition, we explore approaches for determining the HIV share in the cofinancing scenario.

RESULTS

We find that efficient structural interventions may be less likely to be prioritized, financed and taken to scale where sectors evaluate their options in isolation. A cofinancing approach minimizes welfare loss and could be incorporated in a sector budgeting perspective.

CONCLUSION

Structural interventions may be underimplemented and their cross-sectoral benefits foregone. Cofinancing provides an opportunity for multiple HIV, health and development objectives to be achieved simultaneously, but will require effective cross-sectoral coordination mechanisms for planning, implementation and financing.

The costs and benefits of Option B+ for the prevention of mother-to-child transmission of HIV

OBJECTIVE

Most countries follow WHO 2010 guidelines for the prevention of mother-to-child transmission (PMTCT) of HIV using either Option A or B for women not yet eligible for antiretroviral therapy (ART). Both of these approaches involve the use of antiretrovirals during pregnancy and breastfeeding. Some countries have adopted a new strategy, Option B+, in which HIV-positive pregnant women are started immediately on ART and continued for life. Option B+ is more costly than Options A or B, but provides additional health benefits. In this article, we estimate the additional costs and effectiveness of Option B+.

METHODS

We developed a deterministic model to simulate births, breastfeeding, and HIV infection in women in four countries, Kenya, Zambia, South Africa, and Vietnam that differ in fertility rate, birth interval, age at first birth, and breastfeeding patterns, but have similar age at HIV infection. We estimated the total PMTCT costs and new child infections under Options A, B, and B+, and measured cost-effectiveness as the incremental PMTCT-related costs per child infection averted. We included adult sexual transmissions averted from ART, the corresponding costs saved, and estimated the total incremental cost per transmission (child and adult) averted.

RESULTS

When considering PMTCT-related costs and child infections, Option B+ was the most cost-effective strategy costing between $6000 and $23 000 per infection averted compared with Option A. Option B+ averted more child infections compared with Option B in all four countries and cost less than Option B in Kenya and Zambia. When including adult sexual transmissions averted, Option B+ cost less and averted more infections than Options A and B.

Validation and calibration of a computer simulation model of pediatric HIV infection

Background

Computer simulation models can project long-term patient outcomes and inform health policy. We internally validated and then calibrated a model of HIV disease in children before initiation of antiretroviral therapy to provide a framework against which to compare the impact of pediatric HIV treatment strategies.

Methods

We developed a patient-level (Monte Carlo) model of HIV progression among untreated children <5 years of age, using the Cost-Effectiveness of Preventing AIDS Complications model framework: the CEPAC-Pediatric model. We populated the model with data on opportunistic infection and mortality risks from the International Epidemiologic Database to Evaluate AIDS (IeDEA), with mean CD4% at birth (42%) and mean CD4% decline (1.4%/month) from the Women and Infants’ Transmission Study (WITS). We internally validated the model by varying WITS-derived CD4% data, comparing the corresponding model-generated survival curves to empirical survival curves from IeDEA, and identifying best-fitting parameter sets as those with a root-mean square error (RMSE) <0.01. We then calibrated the model to other African settings by systematically varying immunologic and HIV mortality-related input parameters. Model-generated survival curves for children aged 0-60 months were compared, again using RMSE, to UNAIDS data from >1,300 untreated, HIV-infected African children.

Results

In internal validation analyses, model-generated survival curves fit IeDEA data well; modeled and observed survival at 16 months of age were 91.2% and 91.1%, respectively. RMSE varied widely with variations in CD4% parameters; the best fitting parameter set (RMSE = 0.00423) resulted when CD4% was 45% at birth and declined by 6%/month (ages 0-3 months) and 0.3%/month (ages >3 months). In calibration analyses, increases in IeDEA-derived mortality risks were necessary to fit UNAIDS survival data.

Conclusions

The CEPAC-Pediatric model performed well in internal validation analyses. Increases in modeled mortality risks required to match UNAIDS data highlight the importance of pre-enrollment mortality in many pediatric cohort studies.

What is needed to eliminate new pediatric HIV infections: the contribution of model-based analyses

PURPOSE OF REVIEW

Computer simulation models can identify key clinical, operational, and economic interventions that will be needed to achieve the elimination of new pediatric HIV infections. In this review, we summarize recent findings from model-based analyses of strategies for prevention of mother-to-child HIV transmission (MTCT).

RECENT FINDINGS

In order to achieve elimination of MTCT (eMTCT), model-based studies suggest that scale-up of services will be needed in several domains: uptake of services and retention in care (the PMTCT 'cascade'), interventions to prevent HIV infections in women and reduce unintended pregnancies (the 'four-pronged approach'), efforts to support medication adherence through long periods of pregnancy and breastfeeding, and strategies to make breastfeeding safer and/or shorter. Models also project the economic resources that will be needed to achieve these goals in the most efficient ways to allocate limited resources for eMTCT. Results suggest that currently recommended PMTCT regimens (WHO Option A, Option B, and Option B+) will be cost-effective in most settings.

SUMMARY

Model-based results can guide future implementation science, by highlighting areas in which additional data are needed to make informed decisions and by outlining critical interventions that will be necessary in order to eliminate new pediatric HIV infections.

Optimizing PMTCT service delivery in rural North-Central Nigeria: protocol and design for a cluster randomized study

Nigeria has more HIV-infected women who do not receive needed services for the prevention of mother-to-child transmission of HIV (PMTCT) than any other nation in the world. To meet the UNAIDS/WHO goal of eliminating mother-to-child HIV transmission by 2015, multiple interventions will be required to scale up PMTCT services, especially to lower-level, rural health facilities. To address this, we are conducting a cluster-randomized controlled study to evaluate the impact and cost-effectiveness of a novel, family-focused integrated package of PMTCT services. A systematic re-assignment of patient care responsibilities coupled with the adoption of point-of-care CD4 + cell count testing could facilitate the ability of lower-cadre health providers to manage PMTCT care, including the provision and scale-up of antiretroviral therapy (ART) to pregnant women in rural settings. Additionally, as influential community members, male partners could support their partners' uptake of and adherence to PMTCT care. We describe an innovative approach to scaling up PMTCT service provision that incorporates considerations of where and from whom women can access services (task-shifting), ease of obtaining a CD4 + cell count result (point-of-care testing), the degree of HIV service integration for HIV-infected women and their infants, and the level of family and community involvement (specifically male partner involvement). This systematic approach, if proven feasible and effective, could be scaled up in Nigeria and similar resource-limited settings as a means to accelerate progress toward eliminating mother-to-child transmission of HIV and help women with HIV infection take ART and live long, healthy lives (Trial registration: NCT01805752).

Cost-effectiveness analyses of training: a manager's guide

The evidence on the cost and cost-effectiveness of global training programs is sparse. This manager's guide to cost-effectiveness analysis (CEA) is for professionals who want to recognize and support high quality CEA. It focuses on CEA of training in the context of program implementation or rapid program expansion. Cost analysis provides cost per output and CEA provides cost per outcome. The distinction between these two analyses is essential for making good decisions about value. A hypothetical example of a cost analysis compares the cost per trainee of a computer-based anti-retroviral therapy (ART) training to a more intensive ART training. In a CEA of the same example, cost per trainee who met ART clinical performance standards is compared. The cost analysis is misleading when the effectiveness differs across trainings. Two additional hypothetical examples progress from simple to more complex costs and from a narrow to a broader scope: 1) CEA of the cost per ART patient with 95% adherence that compares the performance of doctors to counselors who attend additional training, and 2) CEA of the cost per infant HIV infection averted for a Prevention of Mother to Child Transmission program that compares the current program to one with additional training. To create an evidence base on CEA of training, more well-designed analyses and data on the cost of training are needed. Analysts should understand more about how capacity is built, how quality is improved within a health facility, and the costs associated with them. Considering the life of an investment in training, evaluations are needed on how many trainees apply the skills taught, how long trainees continue to apply them, and how long the content of the training conforms to national or international guidelines. Better data on effectiveness of training is also needed. It is feasible to measure effectiveness by clinical performance standards, or intermediate outcomes and coverage. Intermediate outcomes and coverage can also be combined with published estimates on health outcomes.

Cost-effectiveness of World Health Organization 2010 guidelines for prevention of mother-to-child HIV transmission in Zimbabwe

BACKGROUND

In 2010, the World Health Organization (WHO) released revised guidelines for prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT). We projected clinical impacts, costs, and cost-effectiveness of WHO-recommended PMTCT strategies in Zimbabwe.

METHODS

We used Zimbabwean data in a validated computer model to simulate a cohort of pregnant, HIV-infected women (mean age, 24 years; mean CD4 count, 451 cells/µL; subsequent 18 months of breastfeeding). We simulated guideline-concordant care for 4 PMTCT regimens: single-dose nevirapine (sdNVP); WHO-recommended Option A, WHO-recommended Option B, and Option B+ (lifelong maternal 3-drug antiretroviral therapy regardless of CD4). Outcomes included maternal and infant life expectancy (LE) and lifetime healthcare costs (2008 US dollars [USD]). Incremental cost-effectiveness ratios (ICERs, in USD per year of life saved [YLS]) were calculated from combined (maternal + infant) discounted costs and LE.

RESULTS

Replacing sdNVP with Option A increased combined maternal and infant LE from 36.97 to 37.89 years and would reduce lifetime costs from $5760 to $5710 per mother-infant pair. Compared with Option A, Option B further improved LE (38.32 years), and saved money within 4 years after delivery ($5630 per mother-infant pair). Option B+ (LE, 39.04 years; lifetime cost, $6620 per mother-infant pair) improved maternal and infant health, with an ICER of $1370 per YLS compared with Option B.

CONCLUSIONS

Replacing sdNVP with Option A or Option B will improve maternal and infant outcomes and save money; Option B increases health benefits and decreases costs compared with Option A. Option B+ further improves maternal outcomes, with an ICER (compared with Option B) similar to many current HIV-related healthcare interventions.

A comparison of frameworks evaluating evidence for global health interventions

Jill Luoto and colleagues apply different frameworks to the same body of evidence for three advocated global health interventions and compare the ratings and policy recommendations resulting from each. Please see later in the article for the Editors' Summary

Lesotho's minimum PMTCT package: lessons learned for combating vertical HIV transmission using co-packaged medicines

Introduction

Mother-to-child transmission of HIV can be reduced to<5% with appropriate antiretroviral medications. Such reductions depend on multiple health system encounters during antenatal care (ANC), delivery and breastfeeding; in countries with limited access to care, transmission remains high. In Lesotho, where 28% of women attending ANC are HIV positive but where geographic and other factors limit access to ANC and facility deliveries, a Minimum PMTCT Package was launched in 2007 as an alternative to the existing facility-based approach. Distributed at the first ANC visit, it packaged together all necessary pregnancy, delivery and early postnatal antiretroviral medications for mother and infant.

Methods

To examine the availability, feasibility, acceptability and possible negative consequences of the Minimum PMTCT Package, data from a 2009 qualitative and quantitative study and a 2010 facility assessment were used. To examine the effects on ANC and facility-based delivery rates, a difference-in-differences analytic approach was applied to 2009 Demographic and Health Survey data for HIV-tested women who gave birth before and after Minimum PMTCT Package implementation.

Results

The Minimum PMTCT Package was feasible and acceptable to providers and clients. Problems with test kit and medicine stock-outs occurred, and 46% of women did not receive the Minimum PMTCT Package until at least their second ANC visit. Providing adequate instruction on the use of multiple medications represented a challenge. The proportion of HIV-positive women delivering in facilities declined after Minimum PMTCT Package implementation, although it increased among HIV-negative women (difference-in-differences=14.5%, p=0.05). The mean number of ANC visits declined more among HIV-positive women than among HIV-negative women after implementation, though the difference was not statistically significant (p=0.09). Changes in the percentage of women receiving≥4 ANC visits did not differ between the two groups.

Conclusions

If supply issues can be resolved and adequate client educational materials provided, take-away co-packages have the potential to increase access to PMTCT commodities in countries where women have limited access to health services. However, efforts must be made to carefully monitor potential changes in ANC visits and facility deliveries, and further evaluation of adherence, safety and effectiveness are needed.

HIV treatment as prevention: optimising the impact of expanded HIV treatment programmes

Until now, decisions about how to allocate ART have largely been based on maximising the therapeutic benefit of ART for patients. Since the results of the HPTN 052 study showed efficacy of antiretroviral therapy (ART) in preventing HIV transmission, there has been increased interest in the benefits of ART not only as treatment, but also in prevention. Resources for expanding ART in the short term may be limited, so the question is how to generate the most prevention benefit from realistic potential increases in the availability of ART. Although not a formal systematic review, here we review different ways in which access to ART could be expanded by prioritising access to particular groups based on clinical or behavioural factors. For each group we consider (i) the clinical and epidemiological benefits, (ii) the potential feasibility, acceptability, and equity, and (iii) the affordability and cost-effectiveness of prioritising ART access for that group. In re-evaluating the allocation of ART in light of the new data about ART preventing transmission, the goal should be to create policies that maximise epidemiological and clinical benefit while still being feasible, affordable, acceptable, and equitable.

Cost-effectiveness of antiretroviral therapy for prevention

Recent empirical studies and analyses have heightened interest in the use of expanded antiretroviral therapy (ART) for prevention of HIV transmission. However, ART is expensive, approximately $600 per person per year, raising issues of the cost and cost-effectiveness of ambitious ART expansion. The goal of this review is to equip the reader with the conceptual tools and substantive background needed to understand and evaluate the policy and programmatic implications of cost-effectiveness assessments of ART for prevention. We provide this review in six sections. We start by introducing and explaining basic concepts of health economics as they relate to this issue, including resources, costs, health metrics (such as Disability-Adjusted Life Years), and different types of economic analysis. We then review research on the cost and cost-effectiveness of ART as treatment, and on the cost-effectiveness of traditional HIV prevention. We describe critical issues in the epidemic impact of ART, such as suppression of transmission and the role of the acute phase of infection. We then present a conceptual model for conducting and interpreting cost-effectiveness analyses of ART as prevention, and review the existing preliminary estimates in this area. We end with a discussion of future directions for programmatic demonstrations and evaluation.

WHO 2010 guidelines for prevention of mother-to-child HIV transmission in Zimbabwe: modeling clinical outcomes in infants and mothers

BACKGROUND

The Zimbabwean national prevention of mother-to-child HIV transmission (PMTCT) program provided primarily single-dose nevirapine (sdNVP) from 2002-2009 and is currently replacing sdNVP with more effective antiretroviral (ARV) regimens.

METHODS

Published HIV and PMTCT models, with local trial and programmatic data, were used to simulate a cohort of HIV-infected, pregnant/breastfeeding women in Zimbabwe (mean age 24.0 years, mean CD4 451 cells/µL). We compared five PMTCT regimens at a fixed level of PMTCT medication uptake: 1) no antenatal ARVs (comparator); 2) sdNVP; 3) WHO 2010 guidelines using "Option A" (zidovudine during pregnancy/infant NVP during breastfeeding for women without advanced HIV disease; lifelong 3-drug antiretroviral therapy (ART) for women with advanced disease); 4) WHO "Option B" (ART during pregnancy/breastfeeding without advanced disease; lifelong ART with advanced disease); and 5) "Option B+:" lifelong ART for all pregnant/breastfeeding, HIV-infected women. Pediatric (4-6 week and 18-month infection risk, 2-year survival) and maternal (2- and 5-year survival, life expectancy from delivery) outcomes were projected.

RESULTS

Eighteen-month pediatric infection risks ranged from 25.8% (no antenatal ARVs) to 10.9% (Options B/B+). Although maternal short-term outcomes (2- and 5-year survival) varied only slightly by regimen, maternal life expectancy was reduced after receipt of sdNVP (13.8 years) or Option B (13.9 years) compared to no antenatal ARVs (14.0 years), Option A (14.0 years), or Option B+ (14.5 years).

CONCLUSIONS

Replacement of sdNVP with currently recommended regimens for PMTCT (WHO Options A, B, or B+) is necessary to reduce infant HIV infection risk in Zimbabwe. The planned transition to Option A may also improve both pediatric and maternal outcomes.