Cost-effectiveness of dual maternal HIV and syphilis testing strategies in high and low HIV prevalence countries: a modelling study

Patricia J Rodriguez,D Allen Roberts,Julianne Meisner,Monisha Sharma,Morkor Newman Owiredu,Bertha Gomez,Maeve B Mello,Alexey Bobrik,Arkadii Vodianyk,Andrew Storey,George Githuka,Thato Chidarikire,Ruanne Barnabas,Magdalena Barr-Dichiara,Muhammad S Jamil,Rachel Baggaley,Cheryl Johnson,Melanie M Taylor,Alison L Drake

doi:10.1016/s2214-109x(20)30395-8

Abstract

SummaryBackgroundDual HIV and syphilis testing might help to prevent mother-to-child transmission (MTCT) of HIV and syphilis through increased case detection and treatment. We aimed to model and assess the cost-effectiveness of dual testing during antenatal care in four countries with varying HIV and syphilis prevalence.MethodsIn this modelling study, we developed Markov models of HIV and syphilis in pregnant women to estimate costs and infant health outcomes of maternal testing at the first antenatal care visit with individual HIV and syphilis tests (base case) and at the first antenatal care visit with a dual rapid diagnostic test (scenario one). We additionally evaluated retesting during late antenatal care and at delivery with either individual tests (scenario two) or a dual rapid diagnosis test (scenario three). We modelled four countries: South Africa, Kenya, Colombia, and Ukraine. Strategies with an incremental cost-effectiveness ratio (ICER) less than the country-specific cost-effectiveness threshold (US$500 in Kenya, $750 in South Africa, $3000 in Colombia, and $1000 in Ukraine) per disability-adjusted life-year averted were considered cost-effective.FindingsRoutinely offering testing at the first antenatal care visit with a dual rapid diagnosis test was cost-saving compared with the base case in all four countries (ICER: –$26 in Kenya,–$559 in South Africa, –$844 in Colombia, and –$454 in Ukraine). Retesting during late antenatal care with a dual rapid diagnostic test (scenario three) was cost-effective compared with scenario one in all four countries (ICER: $270 in Kenya, $260 in South Africa, $2207 in Colombia, and $205 in Ukraine).InterpretationIncorporating dual rapid diagnostic tests in antenatal care can be cost-saving across countries with varying HIV prevalence. Countries should consider incorporating dual HIV and syphilis rapid diagnostic tests as the first test in antenatal care to support efforts to eliminate MTCT of HIV and syphilis.FundingWHO, US Agency for International Development, and the Bill & Melinda Gates Foundation.

Highlights

Dual elimination of mother-to-child transmission (MTCT) of HIV and syphilis is a public health priority
Maternal treatment is highly effective at preventing MTCT of both HIV and syphilis, gaps in maternal testing and treat ment coverage lead to 180 000 infant HIV infections, 355 000 adverse congenital syphilis birth outcomes, and 306 000 non-clinical congenital syphilis cases every year.[1,2]
Model overview and testing scenarios Using a Markov decision analytical model, we did a costeffectiveness analysis of maternal HIV and syphilis testing using individual tests and dual rapid diagnostic tests in Kenya, South Africa, Colombia, and Ukraine— four countries that represent a range of HIV prevalence, syphilis prevalence, and geographical settings

Summary

Introduction

Dual elimination of mother-to-child transmission (MTCT) of HIV and syphilis is a public health priority. As HIV testing coverage has increased, more pregnant women with HIV are aware of their status, of whom 85% have accessed treatment; whereas, only 66% of pregnant women are tested for syphilis, of whom 78% receive treatment.[1,7] Global efforts for prevention of MTCT (PMTCT) of HIV have led to substantial reductions in new paediatric HIV infections, but PMTCT of syphilis has received considerably less attention and success.[1] Maternal treatment is highly effective at preventing MTCT of both HIV and syphilis, gaps in maternal testing and treat ment coverage lead to 180 000 infant HIV infections, 355 000 adverse congenital syphilis birth outcomes, and 306 000 non-clinical congenital syphilis cases every year.[1,2] WHO has set goals to reach elimination of MTCT of HIV and syphilis, including at least 95% of pregnant women receiving antenatal care, 95% tested for HIV and syphilis, and 95% treated for their infection(s).[3,4,5] Yet, by 2020, only 14 countries had received validation by WHO for achieving the elimination of paediatric HIV or congenital syphilis.[1,6]

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