Abstract
BackgroundRwanda's National PMTCT program aims to achieve elimination of new HIV infections in children by 2015. In November 2010, Rwanda adopted the WHO 2010 ARV guidelines for PMTCT recommending Option B (HAART) for all HIV-positive pregnant women extended throughout breastfeeding and discontinued (short course-HAART) only for those not eligible for life treatment. The current study aims to assess the cost-effectiveness of this policy choice.MethodsBased on a cohort of HIV-infected pregnant women in Rwanda, we modelled the cost-effectiveness of six regimens: dual ARV prophylaxis with either 12 months breastfeeding or replacement feeding; short course HAART (Sc-HAART) prophylaxis with either 6 months breastfeeding, 12 months breastfeeding, or 18 months breastfeeding; and Sc-HAART prophylaxis with replacement feeding. Direct costs were modelled based on all inputs in each scenario and related unit costs. Effectiveness was evaluated by measuring HIV-free survival at 18 months. Savings correspond to the lifetime costs of HIV treatment and care avoided as a result of all vertical HIV infections averted.ResultsAll PMTCT scenarios considered are cost saving compared to “no intervention.” Sc-HAART with 12 months breastfeeding or 6 months breastfeeding dominate all other scenarios. Sc-HAART with 12 months breastfeeding allows for more children to be alive and HIV-uninfected by 18 months than Sc-HAART with 6 months breastfeeding for an incremental cost per child alive and uninfected of 11,882 USD. This conclusion is sensitive to changes in the relative risk of mortality by 18 months for exposed HIV-uninfected children on replacement feeding from birth and those who were breastfed for only 6 months compared to those breastfeeding for 12 months or more.ConclusionOur findings support the earlier decision by Rwanda to adopt WHO Option B and could inform alternatives for breastfeeding duration. Local contexts and existing care delivery models should be part of national policy decisions.
Highlights
Rwanda’s National prevention of mother-to-child transmission (PMTCT) program aims to achieve elimination of new human immunodeficiency virus (HIV) infections in children by 2015
The current study aims to test this hypothesis through an analysis of the cost, effectiveness and savings of a range of PMTCT scenarios based on the Rwanda context
With infant daily NVP during 6 months breastfeeding (Option A) 7+ months – mixed feeding Values used to calculate survival at 18 months for HIV exposed uninfected children Breastfeeding for 12 months or more, mortality rate Estimate of Relative risk (RR) of mortality if breastfeeding for 6 months versus breastfeeding for 12 months or more
Summary
Rwanda’s National PMTCT program aims to achieve elimination of new HIV infections in children by 2015. In November 2010, Rwanda adopted the WHO 2010 ARV guidelines for PMTCT recommending Option B (HAART) for all HIVpositive pregnant women extended throughout breastfeeding and discontinued (short course-HAART) only for those not eligible for life treatment. Compared to previously recommended regimens for the prevention of mother-to-child transmission (PMTCT) of HIV in resource-limited settings [4], recent studies in Botswana [5] and Malawi [6] have demonstrated greater effectiveness of various antiretroviral (ARV) regimens including maternal short course HAART (Sc-HAART) from 26–34 weeks of gestation through 6 months post-partum and extended infant nevirapine (NVP) prophylaxis for 28 weeks during breastfeeding in preventing MTCT including during breastfeeding. The recommended duration of breastfeeding by WHO for Options A and B is exclusive breastfeeding through 6 months and continued through 12 months with complementary food [7]
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