Economic Evaluation of an Alternative Drug to Sulfadoxine-Pyrimethamine as Intermittent Preventive Treatment of Malaria in Pregnancy

Abstract

BackgroundIntermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended in HIV-negative women to avert malaria, while this relies on cotrimoxazole prophylaxis (CTXp) in HIV-positive women. Alternative antimalarials are required in areas where parasite resistance to antifolate drugs is high. The cost-effectiveness of IPTp with alternative drugs is needed to inform policy.MethodsThe cost-effectiveness of 2-dose IPTp-mefloquine (MQ) was compared with IPTp-SP in HIV-negative women (Benin, Gabon, Mozambique and Tanzania). In HIV-positive women the cost-effectiveness of 3-dose IPTp-MQ added to CTXp was compared with CTXp alone (Kenya, Mozambique and Tanzania). The outcomes used were maternal clinical malaria, anaemia at delivery and non-obstetric hospital admissions. The poor tolerability to MQ was included as the value of women’s loss of working days. Incremental cost-effectiveness ratios (ICERs) were calculated and threshold analysis undertaken.ResultsFor HIV-negative women, the ICER for IPTp-MQ versus IPTp-SP was 136.30 US$ (2012 US$) (95%CI 131.41; 141.18) per disability-adjusted life-year (DALY) averted, or 237.78 US$ (95%CI 230.99; 244.57), depending on whether estimates from Gabon were included or not. For HIV-positive women, the ICER per DALY averted for IPTp-MQ added to CTXp, versus CTXp alone was 6.96 US$ (95%CI 4.22; 9.70). In HIV-negative women, moderate shifts of variables such as malaria incidence, drug cost, and IPTp efficacy increased the ICERs above the cost-effectiveness threshold. In HIV-positive women the intervention remained cost-effective for a substantial (up to 21 times) increase in cost per tablet.ConclusionsAddition of IPTp with an effective antimalarial to CTXp was very cost-effective in HIV-positive women. IPTp with an efficacious antimalarial was more cost-effective than IPTp-SP in HIV-negative women. However, the poor tolerability of MQ does not favour its use as IPTp. Regardless of HIV status, prevention of malaria in pregnancy with a highly efficacious, well tolerated antimalarial would be cost-effective despite its high price.Trials RegistrationClinicalTrials.gov NCT 00811421; Pan African Trials Registry PACTR2010020001429343 and PACTR2010020001813440

Systematic review of microeconomic analysis of pregnancy-associated malaria

“…Overall, 44% of the studies included primigravidas or women who were pregnant for the second time [ 28 , 31 , 32 , 33 , 34 , 35 , 36 , 42 ] and 39% did not specify the number of pregnancies [ 19 , 20 , 29 , 30 , 38 , 39 , 41 ]; one study conducted an economic evaluation of women who had multiple pregnancies [ 37 ] and two included women with HIV [ 40 , 43 ]. Almost all interventions were performed during the second and third trimesters of pregnancy and those that evaluated LBW and infant death continued follow-up until one month after delivery.…”

“…Added to this is the review which shows that this intervention saves resources for the health provider, patients and their families and constitutes a dominant strategy in the cost-effectiveness plan. Although the IPTp-MQ scheme is also highly cost-effective, low drug tolerance with multiple side effects does not favour its use as a preventive treatment [ 40 ]. Active detection of malaria cases in low endemic regions outside the African continent is recommended [ 58 , 59 , 60 , 61 ]; however, research on the efficacy and cost-effectiveness of this strategy should be improved to lower the complications of PAM in the epidemiological, parasitological and economic aspects as well as in each country's health system coverage.…”

The influence of pregnancy on the pharmacokinetic properties of artemisinin combination therapy (ACT): a systematic review

“…However, with resistance hampering its use, the prospects for an extended PK evaluation of sulfa drug combinations used for IPTp appear to be limited [ 82 ]. The search for suitable alternative drug (combinations) for IPTp is ongoing [ 83 ].…”

Global Call to Action to scale-up coverage of intermittent preventive treatment of malaria in pregnancy: seminar report

“…The study concluded that two doses of IPTp-SP is a highly cost-effective intervention both in terms of prevention of maternal clinical malaria and reduction in neonatal mortality in this context (Table 2 ). Furthermore, provision of IPTp with a more efficacious drug than SP, even if more expensive, may still remain a cost-effective public health measure to prevent malaria in pregnancy, particularly in HIV-infected pregnant women [ 6 ]. The second cost-effectiveness study was based on the meta-analysis of IPTp with three or more IPTp doses of SP versus two doses across a range of African settings [ 7 ].…”