Optimizing HIV retesting during pregnancy and postpartum in four countries: a cost‐effectiveness analysis

Abstract

Introduction: HIV retesting during late pregnancy and breastfeeding can help detect new maternal infections and prevent mother-to-child HIV transmission (MTCT), but the optimal timing and cost-effectiveness of maternal retesting remain uncertain. Methods: We constructed deterministic models to assess the health and economic impact of maternal HIV retesting on a hypothetical population of pregnant women, following initial testing in pregnancy, on MTCT in four countries: South Africa and Kenya (high/intermediate HIV prevalence), and Colombia and Ukraine (low HIV prevalence). We evaluated six scenarios with varying retesting frequencies from late in antenatal care (ANC) through nine months postpartum. We compared strategies using incremental cost-effectiveness ratios (ICERs) over a 20-year time horizon using country-specific thresholds. Results: We found maternal retesting once in late ANC with catch-up testing through six weeks postpartum was cost-effective in Kenya (ICER = $166 per DALY averted) and South Africa (ICER=$289 per DALY averted). This strategy prevented 19% (Kenya) and 12% (South Africa) of infant HIV infections. Adding one or two additional retests postpartum provided smaller benefits (1 to 2 percentage point increase in infections averted versus one retest). Adding three retests during the postpartum period averted additional infections (1 to 3 percentage point increase in infections averted versus one retest) but ICERs ($7639 and in Kenya and $11 985 in South Africa) greatly exceeded the cost-effectiveness thresholds. In Colombia and Ukraine, all retesting strategies exceeded the cost-effectiveness threshold and prevented few infant infections (up to 31 and 5 infections, respectively). Conclusions: In high HIV burden settings with MTCT rates similar to those seen in Kenya and South Africa, HIV retesting once in late ANC, with subsequent intervention, is the most cost-effective strategy for preventing infant HIV infections. In these settings, two HIV retests postpartum marginally reduced MTCT and were less costly than adding three retests. Retesting in low-burden settings with MTCT rates similar to Colombia and Ukraine was not cost-effective at any time point due to very low HIV prevalence and limited breastfeeding. Keywords: maternal HIV retesting; elimination of maternal-to-child HIV transmission; EMTCT; prevention of maternal-to-child HIV transmission; PMTCT; cost-effectiveness analysis; maternal and child health Additional information may be found under the Supporting Information tab for this article.

Implementation of HIV Retesting During Pregnancy and Postpartum in Kenya: A Cross-Sectional Study

“…Recent modeling studies in Kenya suggest that maternal retesting is cost-effective when retesting occurs in late pregnancy with catch-up testing at delivery or 6 weeks postpartum for women without antenatal retesting; however, retesting at 2 or more time points had limited utility and was not cost-effective. 20 In our study, HIV incidence during pregnancy and postpartum was 0.50/100 PY, which was lower than other recent studies of HIV incidence in Kenya and other parts of sub-Saharan Africa, 2,21-24 and may reflect declines in HIV incidence in Kenya. As scale-up of implementation a All women enrolled in the cross-sectional and programmatic abstraction only studies at all sites; retesting conducted as part of the cross-sectional study procedures was omitted.…”

Impact and cost-effectiveness of frequent HIV re-testing among key populations in Viet Nam: a modeling study

“…26–28 Nevertheless, more frequent HIV testing and faster scale-up of ART alone is unlikely to be sufficient to reach virtual elimination of HIV. 29 Other modeling efforts have suggested that even universal ART coverage by 6 months following infection can leave notable levels of residual incidence from transmission during the acute infection period. 30 Therefore, further scaling up HIV prevention services, facilitated through increased HIV testing, will have an impact on both HIV prevention and mortality reduction.…”

Mobile solutions to Empower reproductive life planning for women living with HIV in Kenya (MWACh EMPOWER): Protocol for a cluster randomized controlled trial

“…cRCT outcome data and the micro-costing data will be used to estimate the average cost per FP user. An existing MTCT Markov model used to measure health impact of maternal HIV retesting in Kenya, including upstream elements related to pregnancy risk and unintended pregnancy [ 46 , 47 ] will be adapted to include estimates of unintended pregnancies including unmet need for FP among WLWH (from Mobile WACh Empower trial), vertical transmission rates in Kenya, current maternal ART and infant ARV regimens, and contraceptive failure rates from LMICs. Model parameters will include time since HIV diagnosis, ART use, ART adherence, HIV viral suppression, breastfeeding status, and infant ARV use.…”