Cost-Effectiveness of Universal Repeat Screening for HIV in the Third Trimester of Pregnancy

Abstract

Screening all pregnant individuals for HIV in the first trimester in pregnancy has long been the standard of care in the United States, with only select populations deemed at higher risk receiving repeat screening in the third trimester. However, HIV acquisition during pregnancy significantly increases the risk of mother-to-child transmission (MTCT), and questions remain as to whether broadening third trimester screening would be effective in reducing MTCT in a cost-effective manner. A decision-analytic model was constructed to compare two strategies: screening for HIV in the first trimester alone vs addition of repeat screening in the third trimester. Probabilities, costs, and utilities were derived from the literature and varied in sensitivity analyses. The assumed incidence of HIV in pregnancy was 0.029%. Outcomes included costs (in 2022 USD), maternal and neonatal quality-adjusted life years (QALYs), and cases of neonatal HIV. Our theoretical cohort contained 3.8 million pregnant individuals, the approximate number of births in the US in 2020. The willingness to pay threshold was set at $100,000/QALY. We performed tornado analysis and univariable sensitivity analyses to determine inputs that most impacted the model. Universal third trimester screening prevented 209 cases of neonatal HIV in this theoretical cohort. Universal third trimester screening led to an increased cost of $600.7 million and 6,118 increased QALYs, with an incremental cost-effectiveness ratio (ICER) of $98,188.82/QALY, less than the WTP threshold. In a univariate sensitivity analysis, third trimester screening remained cost-effective with variation of HIV incidence in pregnancy to as low as 0.027%. In a theoretical US-based cohort of pregnant individuals, universal repeat screening for HIV in the third trimester was found to be both cost-effective and to reduce vertical transmission of HIV. These results merit consideration of a broader HIV screening program in the third trimester.View Large Image Figure ViewerDownload Hi-res image Download (PPT)