Abstract
IntroductionUptake of early infant HIV diagnosis (EID) varies widely across sub‐Saharan African settings. We evaluated the potential clinical impact and cost‐effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation.MethodsUsing the CEPAC‐Pediatric model, we compared two strategies for infants born in 2017 in Côte d’Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six‐week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six‐week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen‐and‐test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six‐week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen‐and‐test were 80%. Costs included NAT ($24/infant), maternal screening ($10/mother–infant pair), ART ($5 to 31/month) and HIV care ($15 to 190/month). Model outcomes included mother‐to‐child transmission of HIV (MTCT) among HIV‐exposed infants, and life expectancy (LE) and mean lifetime per‐person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost‐effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost‐effectiveness thresholds in each country: (1) the per‐capita GDP ($1720/6380/2150) per year‐of‐life saved (YLS), and (2) the CEPAC‐generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second‐line ART; $520/500/580/YLS).ResultsWith EID, projected six‐week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen‐and‐test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by $17 to 22/child (all children). The ICER of screen‐and‐test compared to EID was $1340/YLS (CI), $650/YLS (SA) and $670/YLS (Zimbabwe), below the per‐capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries.ConclusionsUniversal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV‐related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.
Highlights
Uptake of early infant HIV diagnosis (EID) varies widely across sub-Saharan African settings
ANC, antenatal care; ART, antiretroviral therapy; EID, early infant diagnosis; EPI, expanded programme on immunization; IP, intrapartum; IU, intrauterine; mother-to-child transmission of HIV (MTCT), mother-to-child transmission; nucleic acid testing (NAT), nucleic acid test; opportunistic infections (OIs), opportunistic infection; PP, postpartum; PY, person-years; rapid diagnostic testing (RDT), rapid diagnostic test; SD, standard deviation. aMaternal knowledge of HIV status was calculated from the product of ANC coverage and frequency of HIV testing in ANC in each country.; bBased on available data, for Co^te d’Ivoire (CI) and South Africa (SA) we modelled costs of care for individual OIs; in Zimbabwe, OI care was included in overall monthly care costs.; cCD4% is used for ages
We varied key epidemic-specific parameters, uptake at each care “cascade” step for EID and screen-and-test, and costs of diagnostics and HIV care. We first varied these parameters through their published ranges, where available, to identify the impact of data uncertainty on results, including: maternal HIV prevalence, knowledge of HIV status, HIV incidence and ART coverage during pregnancy and breastfeeding; uptake of existing EID programmes; immunization coverage; and cost of infant NAT
Summary
In 2019, more than 1.2 million infants were born to women with HIV worldwide and 150,000 acquired HIV [1]. To improve access to EID, pilot projects have demonstrated the feasibility and acceptability of maternal HIV screening at infant six-week expanded programme on immunization (EPI) visits, where attendance is often >90% [5,6,7,8,9]. This practice can identify HIV-exposed infants not engaged in existing EID programmes and mothers who need ART, simultaneously improving maternal health and reducing the risk of HIV transmission to breastfed, HIV-uninfected children. We used a validated computer simulation model to examine the clinical impact and cost-effectiveness of adding routine maternal HIV screening at immunization visits, with referral to infant HIV testing at existing EID programmes in Co^te d’Ivoire (CI), South Africa (SA) and Zimbabwe
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