Universal Rapid Human Immunodeficiency Virus Screening at Delivery: A Cost-Effectiveness Analysis.

Rachel K Scott,Stacia Crochet,Chun-Chih Huang

doi:10.1155/2018/6024698

Abstract

Objective To determine the cost-effectiveness of universal maternal HIV screening at time of delivery to decrease mother-to-child transmission (MTCT), by comparing the cost and quality-adjusted life years (QALYs) of universal rapid HIV screening at time of delivery to two current standards of care for prenatal HIV screening in the United States. Study Design We conducted a cost-effectiveness analysis to compare the cost and QALY of universal intrapartum rapid HIV screening with two current standards of care: (I) opt-out rapid HIV testing limited to patients without previous third-trimester screening and (II) opt-out rapid HIV testing limited to patients without any prenatal screening. We developed a decision-tree model and performed sensitivity analyses to estimate the impact of variances in QALY, estimated lifetime medical costs, HIV prevalence, and cumulative incidence. Results The incremental cost-effectiveness ratio for universal screening was $7,973.45/QALY. The results remained robust to sensitivity analysis, except for annual cumulative incidence. In areas with an annual cumulative incidence rate of <0.02% for reproductive-age women, the incremental cost-effectiveness ratio for the expanded program would exceed $89,926.94/QALY, approaching the commonly applied cost-effectiveness thresholds ($100,000/QALY). Conclusions Intrapartum universal rapid HIV screening to decrease MTCT appears cost-effective in populations with high HIV incidence in the United States.

Highlights

Mother-to-child transmission (MTCT) of Human Immunodeficiency Virus (HIV) is largely preventable through early diagnosis and antiretroviral therapy (ART), including maternal and neonatal prophylaxis globally and cesarean delivery (CD) for high or unknown viral load in resourcerich settings
We conducted a cost-effectiveness analysis from the societal perspective to compare cost and quality-adjusted life years (QALYs) of our optout intrapartum universal rapid HIV screening strategy with the two current alternative standards of care: standard of care I, opt-out rapid HIV screening limited to patients without previous third-trimester HIV screening; standard of care II, opt-out rapid HIV screening limited to patients without any prenatal HIV screening
After Institutional Review Board approval from the MedStar Health Research Institute (#2015-069), we developed a decision-tree model to analyze the cost-effectiveness of universal, opt-out, rapid HIV screening of pregnant patients admitted for delivery, taking into account the incremental lifetime costs and the loss of QALY associated with MTCT and perinatally acquired HIV (PAH)

Summary

Introduction

Mother-to-child transmission (MTCT) of Human Immunodeficiency Virus (HIV) is largely preventable through early diagnosis and antiretroviral therapy (ART), including maternal and neonatal prophylaxis globally and cesarean delivery (CD) for high or unknown viral load in resourcerich settings. The Centers for Disease Control (CDC) and the American College of Obstetricians and Gynecologists (ACOG) both recommend HIV screening as early as possible in pregnancy and rapid screening in labor if patients have not had prior prenatal screening. High incidence and prevalence communities, and medical centers with a screen-positive rate of greater than one per 1,000, ACOG recommends additional third-trimester screening prior to 36 weeks of gestation [2,3,4,5]. Based upon the CDC and ACOG recommendations, the standard of care in high prevalence communities is to perform a rapid HIV screen on patients in labor who have not had third-trimester screening and in low-incidence and low risk populations is to perform rapid screening in labor if there has been no previous HIV screening during pregnancy. Prenatal screening at T3, HIV+ detected Absent US SC1 SC2

Methods

Results

Conclusion