The Cost-Effectiveness of Different Feeding Patterns Combined with Prompt Treatments for Preventing Mother-to-Child HIV Transmission in South Africa: Estimates from Simulation Modeling

Abstract

ObjectivesBased on the important changes in South Africa since 2009 and the Antiretroviral Treatment Guideline 2013 recommendations, we explored the cost-effectiveness of different strategy combinations according to the South African HIV-infected mothers' prompt treatments and different feeding patterns.Study DesignA decision analytic model was applied to simulate cohorts of 10,000 HIV-infected pregnant women to compare the cost-effectiveness of two different HIV strategy combinations: (1) Women were tested and treated promptly at any time during pregnancy (Promptly treated cohort). (2) Women did not get testing or treatment until after delivery and appropriate standard treatments were offered as a remedy (Remedy cohort). Replacement feeding or exclusive breastfeeding was assigned in both strategies. Outcome measures included the number of infant HIV cases averted, the cost per infant HIV case averted, and the cost per life year(LY) saved from the interventions. One-way and multivariate sensitivity analyses were performed to estimate the uncertainty ranges of all outcomes.ResultsThe remedy strategy does not particularly cost-effective. Compared with the untreated baseline cohort which leads to 1127 infected infants, 698 (61.93%) and 110 (9.76%) of pediatric HIV cases are averted in the promptly treated cohort and remedy cohort respectively, with incremental cost-effectiveness of $68.51 and $118.33 per LY, respectively. With or without the antenatal testing and treatments, breastfeeding is less cost-effective ($193.26 per LY) than replacement feeding ($134.88 per LY), without considering the impact of willingness to pay.ConclusionCompared with the prompt treatments, remedy in labor or during the postnatal period is less cost-effective. Antenatal HIV testing and prompt treatments and avoiding breastfeeding are the best strategies. Although encouraging mothers to practice replacement feeding in South Africa is far from easy and the advantages of breastfeeding can not be ignored, we still suggest choosing replacement feeding as far as possible.

Cost-effectiveness of HIV Prevention Interventions in Sub-Saharan Africa: A Systematic Review

“…1). These 60 peer-reviewed studies provided cost-effectiveness results for the following HIV prevention interventions: 14 studies on VMMC, 13 studies on PrEP, five studies on TasP, 15 studies on PMTCT, nine studies on other biomedical interventions, one study on behaviour change, and three studies on structural interventions [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74]. Among PMTCT studies, 14 considered Prong III strategies, while one focused on Prong II.

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“…Outcome measures were presented as number of HIV infections averted (HIA) for a specific scenario, with fewer studies reporting quality-adjusted life years (QALYs) gained or disability-adjusted life years (DALYs) averted. A number of studies did not provide numerical values for cost-effectiveness measures but rather stated whether an intervention was a dominant (cost-savings with better outcomes) or dominated (costlier with poorer outcomes) strategy [55], [58], [67]. The most cost-effective interventions included -$8356 per HIA for a microbicide intervention in South Africa, −$312 per HIA for a PMTCT intervention in Malawi, and $470 per HIA for a VMMC intervention in Uganda [18], [49], [62].…”

Modeling and Cost-Effectiveness in HIV Prevention

“…Multiple studies have evaluated these recommendations in low-income countries and concluded that they are cost-effective, if not cost-saving [19-22]. The cost per infant infection averted reported in these studies for Option B+ ranged from $1,400 to $23,000, depending on the country [19 - 22] and the cost per QALY gained of B+ compared to B was estimated at $785 in Ghana [19]. Among recent studies published, there is variation in outcomes: estimates by Gopalappa et al were substantially higher than values reported in other studies in the same country.…”

“…Among recent studies published, there is variation in outcomes: estimates by Gopalappa et al were substantially higher than values reported in other studies in the same country. For example, in Zambia, the cost per infant infection averted was reported to be $1,406 by Ishikawa [21] and $6,780 by Gopalappa [20], and in South Africa the cost per infant infection averted was reported at $2,060 by Yu [22] and $23,000 by Gopalappa [20]. These discrepancies are likely due to assumptions made in the models, including breastfeeding duration, rates of ART coverage, ART cost, and whether the analysis included the impact on sero-negative partners (rather than just on mother-to-child transmission).…”

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

“…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].…”