Abstract
BackgroundHIV-infected infants have high risk of death in the first two years of life if untreated. WHO guidelines recommend early infant HIV diagnosis (EID) of all HIV-exposed infants and immediate antiretroviral therapy (ART) in HIV-infected children under 24-months. We assessed the cost-effectiveness of this strategy in HIV-exposed non-breastfed children in Thailand.MethodsA decision analytic model of HIV diagnosis and disease progression compared: EID using DNA PCR with immediate ART (Early-Early); or EID with deferred ART based on immune/clinical criteria (Early-Late); vs. clinical/serology based diagnosis and deferred ART (Reference). The model was populated with survival and cost data from a Thai observational cohort and the literature. Incremental cost-effectiveness ratio per life-year gained (LYG) was compared against the Reference strategy. Costs and outcomes were discounted at 3%.ResultsMean discounted life expectancy of HIV-infected children increased from 13.3 years in the Reference strategy to 14.3 in the Early-Late and 17.8 years in Early-Early strategies. The mean discounted lifetime cost was $17,335, $22,583 and $29,108, respectively. The cost-effectiveness ratio of Early-Late and Early-Early strategies was $5,149 and $2,615 per LYG, respectively as compared to the Reference strategy. The Early-Early strategy was most cost-effective at approximately half the domestic product per capita per LYG ($4,420 in Thailand 2011). The results were robust in deterministic and probabilistic sensitivity analyses including varying perinatal transmission rates.ConclusionIn Thailand, EID and immediate ART would lead to major survival benefits and is cost- effective. These findings strongly support the adoption of WHO recommendations as routine care.
Highlights
In 2011, there were an estimated 330,000 infants newly infected with HIV through mother-to-child transmission (MTCT), over 90% of whom were in sub-Saharan Africa and Asia [1]
Among children initiated on antiretroviral therapy (ART) under 12-months old, the model projected poorer survival as compared to that observed in PHPT cohort, but projections were within the 95% confidence interval of the survival estimate, most likely due to the small sample size in this age group(Table S3 in File S1)
Among children initiated on ART after 12-months of age, projected survival was within 2% of that observed in the PHPT cohort
Summary
In 2011, there were an estimated 330,000 infants newly infected with HIV through mother-to-child transmission (MTCT), over 90% of whom were in sub-Saharan Africa and Asia [1]. The risk of early mortality on ART remains high among infants initiating therapy after presenting with symptoms or immunosuppression, with 14% to 27% deaths during the first year of therapy [7,8,9]. The WHO guidelines were subsequently revised in 2008 to recommend immediate ART in all HIV-infected infants under 12-months, irrespective of clinical or immune status [11]. HIV-infected infants have high risk of death in the first two years of life if untreated. WHO guidelines recommend early infant HIV diagnosis (EID) of all HIV-exposed infants and immediate antiretroviral therapy (ART) in HIVinfected children under 24-months. We assessed the cost-effectiveness of this strategy in HIV-exposed non-breastfed children in Thailand
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