Comparative cost-effectiveness of Option B+ for prevention of mother-to-child transmission of HIV in Malawi

Abstract

Objective To estimate the cost-effectiveness of prevention of mother to child transmission (MTCT) of HIV with lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women (‘Option B+’) compared to ART during pregnancy or breastfeeding only unless clinically indicated (‘Option B’). Design Mathematical modelling study of first and second pregnancy, informed by data from the Malawi Option B+ programme. Methods Individual-based simulation model. We simulated cohorts of 10,000 women and their infants during two subsequent pregnancies, including the breastfeeding period, with either Option B+ or B. We parameterised the model with data from the literature and by analysing programmatic data. We compared total costs of ante-natal and post-natal care, and lifetime costs and disability-adjusted life-years (DALYs) of the infected infants between Option B+ and Option B. Results During the first pregnancy, 15% of the infants born to HIV-infected mothers acquired the infection. With Option B+, 39% of the women were on ART at the beginning of the second pregnancy, compared to 18% with Option B. For second pregnancies, the rates MTCT were 11.3% with Option B+ and 12.3% with Option B. The incremental cost-effectiveness ratio comparing the two options ranged between about US$ 500 and US$ 1300 per DALY averted. Conclusion Option B+ prevents more vertical transmissions of HIV than Option B, mainly because more women are already on ART at the beginning of the next pregnancy. Option B+ is a cost-effective strategy for PMTCT if the total future costs and lost lifetime of the infected infants are taken into account.

Who will be lost? Identifying patients at risk of loss to follow‐up in Malawi. The DREAM Program Experience

“…Our LTFU rate in 2014 was 1.3% (or 202 subjects), which is a very low proportion, demonstrating that successful engagement of patients in care is feasible in resource‐limited settings if there is a programme tailored to patient needs. The WHO B+ approach to care, which was pioneered by Malawi in sub‐Saharan Africa, has also proved to be cost‐effective and successful in enhancing ART use in the HIV‐infected patient population . The LTFU rate observed in our programme is markedly lower than that reported for other programmes in the same geographical region , albeit that the populations and programmes evaluated were inherently different from our cohort and programme (many were prevention of mother‐to‐child HIV transmission programmes), as was the methodology in many studies.…”

Level of quality of option B+PMTCT service provision in public health facilities in Mekelle zone, northern Ethiopia: cross-sectional study

“…Option B+ was first conceived and implemented in Malawi. Preliminary findings of routine Option B+ PMTCT programme in a rural district in Malawi showed a fivefold increase in ART initiation and 88% client retention in the first quarter of its implementation in 2011 [9][10][11].…”

Cost and cost‐effectiveness of transitioning to universal initiation of lifelong antiretroviral therapy for allHIV‐positive pregnant and breastfeeding women in Swaziland

“…In this study, the total cost for PMTCT in the five sites during the study period was US $680 508 under Option A and US $868 426 under Option B+. In comparison, the total programme costs for Option B+ as simulated by Tweya et al ., in Malawi were US $431 910 for a first pregnancy and US $662 074 for a woman's second pregnancy.…”

“…The cost and cost-effectiveness outcomes from this study indicate that there is a robust economic case for pursuing the Option B+ approach in Swaziland and similar settings such as South Africa. This is one of the first studies to present an empirical economic evaluation using primary patient level data as opposed to modelled data as has been done in the recent past [7,[13][14][15][16][17][18][19][20].…”