Health Outcomes and Cost Impact of the New WHO 2013 Guidelines on Prevention of Mother-to-Child Transmission of HIV in Zambia

Ishikawa, Naoko; Shimbo, Takuro; Miyano, Shinsuke; Sikazwe, Izukanji; Mwango, Albert; Ghidinelli, Massimo; Syakantu, Gardner

doi:10.1371/journal.pone.0090991

Cited by 32 publications

(29 citation statements)

References 19 publications

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“…As World Health Organization 2013 ARV guidelines are implemented globally, an increasing percentage of women with HIV will be expected to enter pregnancy already on ARVs. 32 Thus, risks associated with in utero ARV exposures must be considered in order to identify optimal regimens based on their safety profiles.…”

Section: Discussionmentioning

confidence: 99%

Congenital Anomalies and In Utero Antiretroviral Exposure in Human Immunodeficiency Virus–Exposed Uninfected Infants

et al. 2015

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Importance Most studies examining the association of prenatal antiretroviral exposures with congenital anomalies (CAs) in children born to HIV-infected women have been reassuring, but some suggest increased risk with specific antiretrovirals. Objectives To evaluate associations of in utero antiretroviral exposures with CAs in HIV-exposed uninfected children. Design prospective cohort study, the Pediatric HIV/AIDS Cohort Study (PHACS) Surveillance Monitoring of ART Toxicities (SMARTT) study. Setting 22 US medical centers Participants 2580 HIV-exposed, uninfected children enrolled in SMARTT between 2007–2012. Exposures First trimester exposure to any antiretroviral and to specific antiretroviral medications. Main Outcome The primary endpoint was a CA, based on clinician review of infant physical examinations according to the Antiretroviral Pregnancy Registry modification of the Metropolitan Atlanta Congenital Defects Program. Rates of CAs were estimated overall and by birth year. Logistic regression models were used to evaluate associations of CAs with first trimester antiretroviral exposures, adjusting for demographic and maternal characteristics. Results CAs occurred in 175 of 2580 children, yielding a prevalence of 6.78% (95% CI: 5.85–7.82%); there were 242 confirmed major CAs (72 musculoskeletal, 55 cardiovascular). The prevalence of CAs increased significantly in successive birth cohorts (3.8% for children born <2002 up to 8.3% for 2008–2010). In adjusted models, there was no association of first trimester exposures to any antiretroviral, to combination antiretroviral regimens, or to any drug class with CAs. No individual antiretroviral in the reverse transcriptase inhibitor drug classes was associated with increased risk of CAs. Among protease inhibitors, higher odds of CAs were observed for atazanavir (adjusted odds ratio (aOR)=1.93, 95% confidence interval (CI):1.23,3.03) and for ritonavir used as a booster (aOR=1.52, 95%CI: 1.08,2.14). With first trimester atazanavir, risks were highest for skin and musculoskeletal CAs (aORs=5.24 and 2.55, respectively). Conclusions and Relevance Few individual antiretrovirals and no drug classes were associated with increased risk of CAs after adjustment for calendar year and maternal characteristics. While the overall risk remained low, there was a relative increase in successive years and with atazanavir exposure. Given the low absolute CA risk, the benefits of recommended ARV use during pregnancy still outweigh such risks, although further studies are warranted.

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Section: Discussionmentioning

confidence: 99%

Congenital Anomalies and In Utero Antiretroviral Exposure in Human Immunodeficiency Virus–Exposed Uninfected Infants

et al. 2015

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“…Among recent studies published, there is variation in outcomes: estimates by Gopalappa et al were substantially higher than values reported in other studies in the same country. For example, in Zambia, the cost per infant infection averted was reported to be $1,406 by Ishikawa [21] and $6,780 by Gopalappa [20], and in South Africa the cost per infant infection averted was reported at $2,060 by Yu [22] and $23,000 by Gopalappa [20]. These discrepancies are likely due to assumptions made in the models, including breastfeeding duration, rates of ART coverage, ART cost, and whether the analysis included the impact on sero-negative partners (rather than just on mother-to-child transmission).…”

Section: Hiv Prevention Interventionsmentioning

confidence: 99%

Modeling and Cost-Effectiveness in HIV Prevention

Jacobsen

Walensky

2016

Curr HIV/AIDS Rep

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With HIV funding plateauing and the number of people living with HIV increasing due to the roll-out of life-saving antiretroviral therapy, policy makers are faced with increasingly tighter budgets to manage the ongoing HIV epidemic. Cost-effectiveness and modeling analyses can help determine which HIV interventions may be of best value. Incidence remains remarkably high in certain populations and countries, making prevention key to controlling the spread of HIV. This paper briefly reviews concepts in modeling and cost-effectiveness methodology, then examines results of recently published cost-effectiveness analyses on the following HIV prevention strategies: condoms and circumcision, behavioral or community-based interventions, prevention of mother to child transmission, HIV testing, pre-exposure prophylaxis, and treatment as prevention. We find that the majority of published studies demonstrate cost-effectiveness; however, not all interventions are affordable. We urge continued research on combination strategies and methodologies that take into account willingness to pay and budgetary impact.

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“…Recent studies on PMTCT in sub-Saharan Africa, where HIV prevalence is high and universal HIV testing for pregnant women is strongly recommended, analyzed the cost-effectiveness of different options for PMTCT services and concluded that they were cost-effective [7,10–12]. An analysis of PMTCT programmes in New York State between 1998 and 2013 found that every $ 1 invested in PMTCT, $ 4 has been saved in HIV treatment costs; and concluded that it justified the allocation of resources for PMTCT [13].…”

Section: Discussionmentioning

confidence: 99%

“…In addition, we did not discuss or model the potential additional benefits of bundling HIV testing, with syphilis or hepatitis B testing. We adopted a conservative approach and believe that these limitations would, in fact, further strengthen the argument in favour of the universal approach, as the benefits and the cost-effectiveness of PMTCT interventions on maternal health outcomes and prevention of partner infection are well documented [7,11,47]. We are also aware that our scenario did not take into account the non-breastfeeding population, which may have resulted in overestimation of MTCT rates.…”

Section: Discussionmentioning

confidence: 99%

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Should HIV testing for all pregnant women continue? Cost‐effectiveness of universal antenatal testing compared to focused approaches across high to very low HIV prevalence settings

Ishikawa

Dalal

Johnson

et al. 2016

Journal of the International AIDS Society

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IntroductionHIV testing is the entry point for the elimination of mother-to-child transmission of HIV. Decreasing external funding for the HIV response in some low- and middle-income countries has triggered the question of whether a focused approach to HIV testing targeting pregnant women in high-burden areas should be considered. This study aimed at determining and comparing the cost-effectiveness of universal and focused HIV testing approaches for pregnant women across high to very low HIV prevalence settings.MethodsWe conducted a modelling analysis on health and cost outcomes of HIV testing for pregnant women using four country-based case scenarios (Namibia, Kenya, Haiti and Viet Nam) to illustrate high, intermediate, low and very low HIV prevalence settings. We used subnational prevalence data to divide each country into high-, medium- and low-burden areas, and modelled different antenatal and testing coverage in each.ResultsWhen HIV testing services were only focused in high-burden areas within a country, mother-to-child transmission rates remained high ranging from 18 to 23%, resulting in a 25 to 69% increase in new paediatric HIV infections and increased future treatment costs for children. Universal HIV testing was found to be dominant (i.e. more QALYs gained with less cost) compared to focused approaches in the Namibia, Kenya and Haiti scenarios. The universal approach was also very cost-effective compared to focused approaches, with $ 125 per quality-adjusted life years gained in the Viet Nam-based scenario of very low HIV prevalence. Sensitivity analysis further supported the findings.ConclusionsUniversal approach to antenatal HIV testing achieves the best health outcomes and is cost-saving or cost-effective in the long term across the range of HIV prevalence settings. It is further a prerequisite for quality maternal and child healthcare and for the elimination of mother-to-child transmission of HIV.

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Health Outcomes and Cost Impact of the New WHO 2013 Guidelines on Prevention of Mother-to-Child Transmission of HIV in Zambia

Cited by 32 publications

References 19 publications

Congenital Anomalies and In Utero Antiretroviral Exposure in Human Immunodeficiency Virus–Exposed Uninfected Infants

Congenital Anomalies and In Utero Antiretroviral Exposure in Human Immunodeficiency Virus–Exposed Uninfected Infants

Modeling and Cost-Effectiveness in HIV Prevention

Should HIV testing for all pregnant women continue? Cost‐effectiveness of universal antenatal testing compared to focused approaches across high to very low HIV prevalence settings

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