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      Modelling cost-effectiveness of tenofovir for prevention of mother to child transmission of hepatitis B virus (HBV) infection in South Africa

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          Abstract

          Background

          International sustainable development goals for the elimination of viral hepatitis as a public health problem by 2030 highlight the need to optimize strategies for prevention, diagnosis and treatment of hepatitis B virus (HBV) infection. An important priority for Africa is to have affordable, accessible and sustainable prevention of mother to child transmission (PMTCT) programmes, delivering screening and treatment for antenatal women and implementing timely administration of HBV vaccine for their babies.

          Methods

          We developed a decision-analytic model simulating 10,000 singleton pregnancies to assess the cost-effectiveness of three possible strategies for deployment of tenofovir in pregnancy, in combination with routine infant vaccination: S1: no screening nor antiviral therapy; S2: screening and antiviral prophylaxis for all women who test HBsAg-positive; S3: screening for HBsAg, followed by HBeAg testing and antiviral prophylaxis for women who are HBsAg-positive and HBeAg-positive. Our outcome was cost per infant HBV infection avoided and the analysis followed a healthcare perspective.

          Results

          Based on 10,000 pregnancies, S1 predicts 45 infants would be HBV-infected at six months of age, compared to 21 and 28 infants in S2 and S3, respectively. Relative to S1, S2 had an incremental cost of $3940 per infection avoided. S3 led to more infections and higher costs.

          Conclusion

          Given the long-term health burden for individuals and economic burden for society associated with chronic HBV infection, screening pregnant women and providing tenofovir for all who test HBsAg+ may be a cost-effective strategy for South Africa and other low/middle income settings.

          Electronic supplementary material

          The online version of this article (10.1186/s12889-019-7095-4) contains supplementary material.

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          Most cited references23

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          Hepatitis B virus burden in developing countries.

          Hepatitis B virus (HBV) infection has shown an intermediate or high endemicity level in low-income countries over the last five decades. In recent years, however, the incidence of acute hepatitis B and the prevalence of hepatitis B surface antigen chronic carriers have decreased in several countries because of the HBV universal vaccination programs started in the nineties. Some countries, however, are still unable to implement these programs, particularly in their hyperendemic rural areas. The diffusion of HBV infection is still wide in several low-income countries where the prevention, management and treatment of HBV infection are a heavy burden for the governments and healthcare authorities. Of note, the information on the HBV epidemiology is scanty in numerous eastern European and Latin-American countries. The studies on molecular epidemiology performed in some countries provide an important contribution for a more comprehensive knowledge of HBV epidemiology, and phylogenetic studies provide information on the impact of recent and older migratory flows.
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            HBVdb: a knowledge database for Hepatitis B Virus

            We have developed a specialized database, HBVdb (http://hbvdb.ibcp.fr), allowing the researchers to investigate the genetic variability of Hepatitis B Virus (HBV) and viral resistance to treatment. HBV is a major health problem worldwide with more than 350 million individuals being chronically infected. HBV is an enveloped DNA virus that replicates by reverse transcription of an RNA intermediate. HBV genome is optimized, being circular and encoding four overlapping reading frames. Indeed, each nucleotide of the genome takes part in the coding of at least one protein. However, HBV shows some genome variability leading to at least eight different genotypes and recombinant forms. The main drugs used to treat infected patients are nucleos(t)ides analogs (reverse transcriptase inhibitors). Unfortunately, HBV mutants resistant to these drugs may be selected and be responsible for treatment failure. HBVdb contains a collection of computer-annotated sequences based on manually annotated reference genomes. The database can be accessed through a web interface that allows static and dynamic queries and offers integrated generic sequence analysis tools and specialized analysis tools (e.g. annotation, genotyping, drug resistance profiling).
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              Epidemiology and impact of HIV coinfection with hepatitis B and hepatitis C viruses in Sub-Saharan Africa.

              Human immunodeficiency virus (HIV), Hepatitis B (HBV) and Hepatitis C (HCV) are blood-borne viruses with potentially shared routes of transmission. In high-income settings, the impact of antiretroviral therapy (ART) on survival has unmasked chronic liver disease from viral hepatitis B or hepatitis C as a leading cause of morbidity and mortality in individuals with HIV infection. It is now feared that progressive liver disease may threaten the success of ART programmes in developing countries, where HCV or HBV testing and monitoring are not yet systematic among HIV-infected patients and ART use is generally blind to these co-infections. We set out to review recent data from Sub-Saharan Africa, in order to build a detailed and up-to-date picture of the epidemiology and emerging impact of HBV and HCV coinfection in countries at the heart of the HIV pandemic. There is a preponderance of HIV/HBV coinfection compared to HIV/HCV in this region, and significant caveats exist regarding the accuracy of published HCV seroprevalence surveys. Morbidity and mortality of coinfection is significant, and may be further enhanced in African populations due to the influence of host, viral and environmental factors. Careful scrutiny of the coinfection problem is vital to inform an approach to directing resources, planning public health initiatives, providing clinical care, and guiding future research. Copyright © 2014 Elsevier B.V. All rights reserved.
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                Author and article information

                Contributors
                philippa.matthews@ndm.ox.ac.uk
                Journal
                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central (London )
                1471-2458
                26 June 2019
                26 June 2019
                2019
                : 19
                : 829
                Affiliations
                [1 ]ISNI 0000 0004 1936 8948, GRID grid.4991.5, Nuffield Department of Medicine, ; Medawar Building, South Parks Road, Oxford, OX1 3SY UK
                [2 ]ISNI 0000 0004 1936 8948, GRID grid.4991.5, Centre for Statistics in Medicine, , University of Oxford, ; Oxford, OX3 7LD UK
                [3 ]ISNI 0000 0001 2214 904X, GRID grid.11956.3a, Division of Medical Virology, Faculty of Medicine and Health Sciences, , Stellenbosch University, ; Francie van Zijl Drive, Tygerberg, 8000 Cape Town Republic of South Africa
                [4 ]ISNI 0000 0001 2284 638X, GRID grid.412219.d, Division of Virology, , University of the Free State/National Health Laboratory Service, ; PO Box 339(G23), Bloemfontein, 9300 Republic of South Africa
                [5 ]ISNI 0000 0001 2306 7492, GRID grid.8348.7, Department of Hepatology, , Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, ; Headley Way, Oxford, OX3 9DU UK
                [6 ]ISNI 0000 0001 2306 7492, GRID grid.8348.7, National Institute of Health Research, Oxford Biomedical Research Centre, John Radcliffe Hospital, ; Headley Way, Headington, Oxford, OX3 9DU UK
                [7 ]ISNI 0000 0001 2306 7492, GRID grid.8348.7, Department of Microbiology and Infectious Diseases, , Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, ; Headley Way, Oxford, OX3 9DU UK
                Author information
                http://orcid.org/0000-0002-4036-4269
                Article
                7095
                10.1186/s12889-019-7095-4
                6595556
                31242901
                4a2f00ad-9fb3-4d99-8cf4-be62cabe620d
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 19 December 2018
                : 31 May 2019
                Funding
                Funded by: Leverhulme Mandela Rhodes Scholarship
                Award ID: None
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/100010269, Wellcome Trust;
                Award ID: 110110
                Funded by: Medical Research Council UK, Oxford NIHR Biomedical Research Centre
                Award ID: None
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2019

                Public health
                tenofovir,hepatitis b,hbv,pmtct,elimination,transmission,epidemiology,africa
                Public health
                tenofovir, hepatitis b, hbv, pmtct, elimination, transmission, epidemiology, africa

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