Optimizing infant HIV diagnosis with additional screening at immunization clinics in three sub‐Saharan African settings: a cost‐effectiveness analysis

Abstract

Introduction Uptake of early infant HIV diagnosis (EID) varies widely across sub‐Saharan African settings. We evaluated the potential clinical impact and cost‐effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation. Methods Using the CEPAC‐Pediatric model, we compared two strategies for infants born in 2017 in Côte d’Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six‐week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six‐week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen‐and‐test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six‐week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen‐and‐test were 80%. Costs included NAT ($24/infant), maternal screening ($10/mother–infant pair), ART ($5 to 31/month) and HIV care ($15 to 190/month). Model outcomes included mother‐to‐child transmission of HIV (MTCT) among HIV‐exposed infants, and life expectancy (LE) and mean lifetime per‐person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost‐effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost‐effectiveness thresholds in each country: (1) the per‐capita GDP ($1720/6380/2150) per year‐of‐life saved (YLS), and (2) the CEPAC‐generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second‐line ART; $520/500/580/YLS). Results With EID, projected six‐week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen‐and‐test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by $17 to 22/child (all children). The ICER of screen‐and‐test compared to EID was $1340/YLS (CI), $650/YLS (SA) and $670/YLS (Zimbabwe), below the per‐capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries. Conclusions Universal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV‐related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.

Cost-effectiveness of Routine Provider-Initiated Testing and Counseling for Children With Undiagnosed HIV in South Africa

“…This study was subject to several limitations. First, we excluded children age <2, who may account for substantial HIV-related mortality and health care utilization; although young children eligible only for virologic assays are beyond the scope of the current study, they have been the focus of previous CEPAC work [ 37 ]. Second, there is a lack of current, South Africa–specific data for each of the 4 clinical settings about age of presentation to care, prevalence of undiagnosed HIV, and CD4/CD4% among children with HIV seeking care.…”

Costs and cost-effectiveness of HIV early infant diagnosis in low- and middle-income countries: a scoping review

“…Unit costs per test are reported in Table 1. Seven studies reported unit costs for PoC assays [13,40,[50][51][52][53][54], 13 for laboratory testing [13,24,38,39,41,44,46,[50][51][52][53][54][55], two for rapid testing [41,56], and one for unspecified NAT [57] Variation in unit costs for PoC assays may be explained by inclusion of capital costs. Costs for m-PIMA that included equipment costs were > 20 USD higher than those that did not include equipment costs.…”

“…Few studies assessed the same intervention or reported costs in the same way, making comparison of costs across studies challenging. Most studies evaluated costs or cost-effectiveness of EID testing approaches including four studies on PoC EID [45,50,52,53], three on birth testing [24,44,59], one study that assessed both PoC and improvements to centralized EID [51], one that reported costs of confirmatory testing in EID programs [54], one of added screening of mothers at 6-week infant immunization visits with referral to EID for infants at risk of acquiring HIV [57], and one of rapid antibody screening to rule out negative infants before NAT [41].…”

“…Included studies used the Cost-Effectiveness of Preventing AIDS Complications Pediatric model [24,27,51,54,57,64] (i.e., a validated state transition model simulating individual costs and HIV disease outcomes [65,66]), decision tree models [41,43,53,59], and cohort state transition simulation models [38,50]. Seven studies used a lifetime horizon for the model [24,27,38,51,52,54,57], while the remaining used time horizons of 5 years [53], 2 years [59], 1 year [43], and 18 months [41,50].…”

“…Included studies used the Cost-Effectiveness of Preventing AIDS Complications Pediatric model [24,27,51,54,57,64] (i.e., a validated state transition model simulating individual costs and HIV disease outcomes [65,66]), decision tree models [41,43,53,59], and cohort state transition simulation models [38,50]. Seven studies used a lifetime horizon for the model [24,27,38,51,52,54,57], while the remaining used time horizons of 5 years [53], 2 years [59], 1 year [43], and 18 months [41,50]. Nine studies used a discount rate of 3% per year for both costs and health benefits [24,27,38,41,43,51,52,54,57], two studies reported only undiscounted costs and benefits [50,53], and one study, an abstract, did not specify whether discounting was applied [59,67].…”