Cost-effectiveness of World Health Organization 2010 Guidelines for Prevention of Mother-to-Child HIV Transmission in Zimbabwe

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Abstract

We projected outcomes for mothers and infants following World Health Organization–recommended regimens to prevent mother-to-child human immunodeficiency virus (HIV) transmission. Compared with Option A, Option B improves life expectancy and saves money; compared with Option B, lifelong maternal therapy is of comparable value to common HIV-related interventions.

Abstract

Background. In 2010, the World Health Organization (WHO) released revised guidelines for prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT). We projected clinical impacts, costs, and cost-effectiveness of WHO-recommended PMTCT strategies in Zimbabwe.

Methods. We used Zimbabwean data in a validated computer model to simulate a cohort of pregnant, HIV-infected women (mean age, 24 years; mean CD4 count, 451 cells/µL; subsequent 18 months of breastfeeding). We simulated guideline-concordant care for 4 PMTCT regimens: single-dose nevirapine (sdNVP); WHO-recommended Option A, WHO-recommended Option B, and Option B+ (lifelong maternal 3-drug antiretroviral therapy regardless of CD4). Outcomes included maternal and infant life expectancy (LE) and lifetime healthcare costs (2008 US dollars [USD]). Incremental cost-effectiveness ratios (ICERs, in USD per year of life saved [YLS]) were calculated from combined (maternal + infant) discounted costs and LE.

Results. Replacing sdNVP with Option A increased combined maternal and infant LE from 36.97 to 37.89 years and would reduce lifetime costs from $5760 to $5710 per mother–infant pair. Compared with Option A, Option B further improved LE (38.32 years), and saved money within 4 years after delivery ($5630 per mother–infant pair). Option B+ (LE, 39.04 years; lifetime cost, $6620 per mother–infant pair) improved maternal and infant health, with an ICER of $1370 per YLS compared with Option B.

Conclusions. Replacing sdNVP with Option A or Option B will improve maternal and infant outcomes and save money; Option B increases health benefits and decreases costs compared with Option A. Option B+ further improves maternal outcomes, with an ICER (compared with Option B) similar to many current HIV-related healthcare interventions.

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Recommendations of the Panel on Cost-effectiveness in Health and Medicine.

M Weinstein, J E Siegel, M R Gold … (1996)

To develop consensus-based recommendations for the conduct of cost-effectiveness analysis (CEA). This article, the second in a 3-part series, describes the basis for recommendations constituting the reference case analysis, the set of practices developed to guide CEAs that inform societal resource allocation decisions, and the content of these recommendations. The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS). The panel reviewed the theoretical foundations of CEA, current practices, and alternative methods used in analyses. Recommendations were developed on the basis of theory where possible, but tempered by ethical and pragmatic considerations, as well as the needs of users. The panel developed recommendations through 2 1/2 years of discussions. Comments on preliminary drafts prepared by panel working groups were solicited from federal government methodologists, health agency officials, and academic methodologists. The panel's methodological recommendations address (1) components belonging in the numerator and denominator of a cost-effectiveness (C/E) ratio; (2) measuring resource use in the numerator of a C/E ratio; (3) valuing health consequences in the denominator of a C/E ratio; (4) estimating effectiveness of interventions; (5) incorporating time preference and discounting; and (6) handling uncertainty. Recommendations are subject to the ¿rule of reason,¿ balancing the burden engendered by a practice with its importance to a study. If researchers follow a standard set of methods in CEA, the quality and comparability of studies, and their ultimate utility, can be much improved.

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Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial.

Laura Guay, Philippa Musoke, Thomas Fleming … (1999)

The AIDS Clinical Trials Group protocol 076 zidovudine prophylaxis regimen for HIV-1-infected pregnant women and their babies has been associated with a significant decrease in vertical HIV-1 transmission in non-breastfeeding women in developed countries. We compared the safety and efficacy of short-course nevirapine or zidovudine during labour and the first week of life. From November, 1997, to April, 1999, we enrolled 626 HIV-1-infected pregnant women at Mulago Hospital in Kampala, Uganda. We randomly assigned mothers nevirapine 200 mg orally at onset of labour and 2 mg/kg to babies within 72 h of birth, or zidovudine 600 mg orally to the mother at onset of labour and 300 mg every 3 h until delivery, and 4 mg/kg orally twice daily to babies for 7 days after birth. We tested babies for HIV-1 infection at birth, 6-8 weeks, and 14-16 weeks by HIV-1 RNA PCR. We assessed HIV-1 transmission and HIV-1-free survival with Kaplan-Meier analysis. Nearly all babies (98.8%) were breastfed, and 95.6% were still breastfeeding at age 14-16 weeks. The estimated risks of HIV-1 transmission in the zidovudine and nevirapine groups were: 10.4% and 8.2% at birth (p=0.354); 21.3% and 11.9% by age 6-8 weeks (p=0.0027); and 25.1% and 13.1% by age 14-16 weeks (p=0.0006). The efficacy of nevirapine compared with zidovudine was 47% (95% CI 20-64) up to age 14-16 weeks. The two regimens were well tolerated and adverse events were similar in the two groups. Nevirapine lowered the risk of HIV-1 transmission during the first 14-16 weeks of life by nearly 50% in a breastfeeding population. This simple and inexpensive regimen could decrease mother-to-child HIV-1 transmission in less-developed countries.

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Outcomes after two years of providing antiretroviral treatment in Khayelitsha, South Africa.

David Coetzee, Katherine Hildebrand, Andrew Boulle … (2004)

A community-based antiretroviral therapy (ART) programme was established in 2001 in a South African township to explore the operational issues involved in providing ART in the public sector in resource-limited settings and demonstrate the feasibility of such a service. Data was analysed on a cohort of patients with symptomatic HIV disease and a CD4 lymphocyte count or =50 x 10 cells/l, and 81.8% for those with a baseline CD4 lymphocyte count < 50 x 10 cells/l. The cumulative probability of changing a single antiretroviral drug by 24 months was 15.1% due to adverse events or contraindications, and 8.4% due to adverse events alone. ART can be provided in resource-limited settings with good patient retention and clinical outcomes. With responsible implementation, ART is a key component of a comprehensive response to the epidemic in those communities most affected by HIV.

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Author and article information

Journal

Journal ID (nlm-ta): Clin Infect Dis

Journal ID (iso-abbrev): Clin. Infect. Dis

Journal ID (publisher-id): cid

Journal ID (hwp): cid

Title: Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America

Publisher: Oxford University Press

ISSN (Print): 1058-4838

ISSN (Electronic): 1537-6591

Publication date (Print): 1 February 2013

Publication date (Electronic): 30 November 2012

Publication date PMC-release: 30 November 2012

Volume: 56

Issue: 3

Pages: 430-446

Affiliations

[1 ]Medical Practice Evaluation Center, Divisions of Infectious Disease

[2 ]Division of General Medicine

[3 ]Department of Medicine, Massachusetts General Hospital

[4 ]Division of Infectious Disease, Brigham and Women's Hospital

[5 ]Center for AIDS Research, Harvard Medical School , Boston, Massachusetts

[6 ]Universite Bordeaux, Institut de Santé Publique, d'Epidémiologie et de Développement, and Centre INSERM U897-Epidemiologie-Biostatistique , Bordeaux, France

[7 ]HIV/AIDS Unit, Pan American Health Organization, Washington, DC

[8 ]Organisation for Public Health Interventions and Development

[9 ]Ministry of Health and Child Welfare

[10 ]United States Agency for International Development, Harare, Zimbabwe

[11 ]Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town , South Africa

Author notes

Presented in part: 6th Conference on HIV Pathogenesis, Treatment and Prevention of the International AIDS Society, Rome, Italy, 17–20 July 2011. Abstract TuPE284; 3rd International Workshop for HIV Pediatrics, Rome, Italy, 15–16 July 2011. Abstract P_78.

Correspondence: Andrea L. Ciaranello, MD, MPH, Division of Infectious Disease, Massachusetts General Hospital, 50 Staniford St, 9th Fl, Boston, MA 02114 ( aciaranello@ 123456partners.org ).

Article

Publisher ID: cis858

DOI: 10.1093/cid/cis858

PMC ID: 3540037

PubMed ID: 23204035

SO-VID: a975328b-9ba8-4247-8f09-9cd8fce5d0a4

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This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/3.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

Cost-effectiveness of World Health Organization 2010 Guidelines for Prevention of Mother-to-Child HIV Transmission in Zimbabwe

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Point-of-Care Testing for Infectious Diseases Super Collection

Most cited references 92

Recommendations of the Panel on Cost-effectiveness in Health and Medicine.

Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial.

Outcomes after two years of providing antiretroviral treatment in Khayelitsha, South Africa.

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