Abstract
BackgroundPoor engagement in postpartum maternal HIV care is a challenge worldwide and contributes to adverse maternal outcomes and vertical transmission. Our objective was to project the clinical and economic impact of integrated postpartum maternal antiretroviral therapy (ART) and pediatric care in South Africa.MethodsUsing the CEPAC computer simulation models, parameterized with data from the Maternal and Child Health–Antiretroviral Therapy (MCH-ART) randomized controlled trial, we evaluated the cost-effectiveness of integrated postpartum care for women initiating ART in pregnancy and their children. We compared two strategies: 1) standard of care (SOC) referral to local clinics after delivery for separate standard ART services for women and pediatric care for infants, and 2) the MCH-ART intervention (MCH-ART) of co-located maternal/pediatric care integrated in Maternal and Child Health (MCH) services throughout breastfeeding. Trial-derived inputs included: 12-month maternal retention in care and virologic suppression (SOC: 49%, MCH-ART: 67%), breastfeeding duration (SOC: 6 months, MCH-ART: 8 months), and postpartum healthcare costs for mother-infant pairs (SOC: $50, MCH-ART: $69). Outcomes included pediatric HIV infections, maternal and infant life expectancy (LE), lifetime HIV-related per-person costs, and incremental cost-effectiveness ratios (ICERs; ICER <US$903/YLS considered “cost-effective”).ResultsCompared to SOC, MCH-ART increased maternal LE (SOC: 25.26 years, MCH-ART: 26.20 years) and lifetime costs (SOC: $9,912, MCH-ART: $10,207; discounted). Projected pediatric outcomes for all HIV-exposed children were similar between arms, although undiscounted LE for HIV-infected children was shorter in SOC (SOC: 23.13 years, MCH-ART: 23.40 years). Combining discounted maternal and pediatric outcomes, the ICER was $599/YLS.ConclusionCo-located maternal HIV and pediatric care, integrated in MCH services throughout breastfeeding, is a cost-effective strategy to improve maternal and pediatric outcomes and should be implemented in South Africa.
Highlights
The postpartum period is a high-risk time for women with HIV and their children
Using the CEPAC computer simulation models, parameterized with data from the Maternal and Child Health–Antiretroviral Therapy (MCH-antiretroviral therapy (ART)) randomized controlled trial, we evaluated the cost-effectiveness of integrated postpartum care for women initiating ART in pregnancy and their children
Projected pediatric outcomes for all HIV-exposed children were similar between arms, undiscounted LE for HIV-infected children was shorter in SOC (SOC: 23.13 years, maternal and child health (MCH)-ART: 23.40 years)
Summary
Despite the scale-up of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, approximately 180,000 new pediatric HIV infections occurred worldwide in 2017, including 13,000 in South Africa [1]. High rates of postpartum loss to follow-up (LTFU) and ART non-adherence contribute to adverse maternal outcomes and HIV transmission to breastfeeding infants [2,3,4]. In South Africa, most pregnant women with HIV receive HIV care and ART integrated into antenatal services in MCH clinics [5]. HIV care is transferred to separate general ART services for women and routine pediatric care for children; this is a vulnerable time for disengagement [5]. Our objective was to project the clinical and economic impact of integrated postpartum maternal antiretroviral therapy (ART) and pediatric care in South Africa
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