HIV screening in pregnant women: A systematic review of cost-effectiveness studies

Prevalence of Repeat Prenatal HIV Screening in New York State

Description: New York State Department of Health (NYSDOH) recommends that all pregnant patients receive human immunodeficiency virus (HIV) screening during pregnancy. This study assessed the prevalence of repeat prenatal HIV testing and factors associated with receipt of the recommended tests. Methods: Data from the NYSDOH newborn screening program were used to randomly select pregnant persons without HIV who delivered a liveborn infant in 2017. Receipt of repeat testing was defined as an initial HIV test in the first or second trimesters and the final in the third trimester (relaxed); or an initial test in the first trimester and the final in the third trimester (strict). Relative risks (RRs) and 95% confidence intervals were calculated in bivariate analyses. Adjusted RRs were calculated to determine associations between demographic and clinical factors and receipt of repeat HIV testing. Results: The cohort included 2,225 individuals. Roughly one quarter (24%) received the recommended tests in the first or second and third trimesters and 17% received them in the first and third trimesters. Individuals who reported Hispanic or Asian race/ethnicities, had government-funded insurance, started prenatal care in the first trimester, delivered in New York City, or received prenatal hepatitis C virus screening were significantly more likely to receive repeat testing using either definition. Conclusions: Despite the benefits and cost-effectiveness, the prevalence of repeat prenatal HIV screening during the third trimester remains persistently low. Improved messaging and targeted education and resources to assist prenatal providers could reinforce the importance of repeat testing and reduce residual perinatal HIV transmission.

Exploring the logistics and supply chain services of HIV/AIDS facilities in north-western Nigeria

This study aimed to assess the logistics services of HIV/AIDS facilities in the northwestern states of Nigeria, with a particular focus on the National HIV/AIDS Supply Chain Unification Project. The project aimed to streamline the distribution of antiretroviral drugs, HIV rapid test kits, and co-trimoxazole by establishing a coordinated axial storage location for all healthcare facilities providing HIV/AIDS services in Nigeria. A field visit was conducted, covering hospitals under the Supply Chain Unification Project in the Phase 4 region, which includes Jigawa, Kano, Katsina, Kebbi, Sokoto, and Zamfara States. Fourteen (14) assessors visited one hundred and four (104) health facilities comprising thirty-nine (39) providing comprehensive care sites and sixty-nine (69) sites providing Prevention of Mother-To-Child Transmission (PMTCT) services. An adapted Logistics Indicators Assessment Tool (LIAT) was administered. Data were collated and entered into the pre-designed database on Microsoft (MS) Access. The significant gaps identified during this research included inadequately trained personnel, low levels of availability of Standard Operating Procedures (SOP) manuals, a dearth of firefighting gadgets, and non-use of Personal Computers (PCs) and internet availability for transmission of reports. All these require urgent attention from stakeholders in most of the sites visited. Findings were documented, with follow-up actions to be implemented as appropriate. Findings and recommendations have been communicated to the government, implementing partners, and sub-recipients supporting the facilities. It is expected that the findings from these visits will be used in developing appropriate solutions/next steps to improve the HIV/AIDS commodities supply chain management in the country.

Financing Benefits and Barriers to Routine HIV Screening in Clinical Settings in the United States: A Scoping Review

The Centers for Disease Control and Prevention recommends everyone between 13-64 years be tested for HIV at least once as a routine procedure. Routine HIV screening is reimbursable by Medicare, Medicaid, expanded Medicaid, and most commercial insurance plans. Yet, scaling-up HIV routine screening remains a challenge. We conducted a scoping review for studies on financial benefits and barriers associated with HIV screening in clinical settings in the U.S. to inform an evidence-based strategy to scale-up routine HIV screening. We searched Ovid MEDLINE^®, Cochrane, and Scopus for studies published between 2006-2020 in English. The search identified 383 Citations; we screened 220 and excluded 163 (outside the time limit, irrelevant, or outside the U.S.). Of the 220 screened articles, we included 35 and disqualified 155 (did not meet the eligibility criteria). We organized eligible articles under two themes: financial benefits/barriers of routine HIV screening in healthcare settings (9 articles); and Cost-effectiveness of routine screening in healthcare settings (26 articles). The review concluded drawing recommendations in three areas: (1) Finance: Incentivize healthcare providers/systems for implementing HIV routine screening and/or separate its reimbursement from bundle payments; (2) Personnel: Encourage nurse-initiated HIV screening programs in primary care settings and educate providers on CDC recommendations; and (3) Approach: Use opt-out approach.

Supply-side readiness to deliver HIV testing and treatment services in Indonesia: Going the last mile to eliminate mother-to-child transmission of HIV

INTRODUCTION

Despite national efforts to integrate Prevention of Mother-to-Child Transmission (PMTCT) of HIV services into antenatal care in Indonesia, the rate of mother-to-child transmission of HIV remains the highest in the world. A range of barriers to uptake and long-term engagement in care have been identified, but far less is known about health system preparedness to deliver PMTCT of HIV services. This study explored supply-side barriers to the delivery of PMTCT services in Indonesia and whether these factors are associated with the uptake of antenatal HIV testing.

MATERIALS AND METHODS

An ecological analysis was undertaken, linking data from the World Bank Quality Service and Delivery Survey (2016) with routine data from Indonesia's HIV and AIDS case surveillance system and district health profile reports (2016). Supply-side readiness scores-generated from a readiness index that measures overall structural capacity and is often used as proxy for quality of care-were adapted from the WHO Service Availability and Readiness Assessment and presented by sector and geographic area. Univariate and multivariate regression analysis was used to explore factors associated with the uptake of antenatal HIV testing in public facilities.

RESULTS

In general, public facilities scored more highly in most inputs compared to private facilities. Facilities located in urban areas also scored more highly in the majority of inputs compared to ones in rural areas. Readiness scores were lowest for PMTCT services compared to Antenatal Care and HIV Care and Support services, especially for the availability of medicines such as zidovudine and nevirapine. The national composite readiness score for PMTCT was only 0.13 (based on a maximum score of 1) with a composite score of 0.21 for public facilities and 0.06 for private facilities. The multivariate analysis shows that the proportion of pregnant women tested for HIV was more likely to be greater than or equal to 10% in facilities with a higher readiness score and a higher number of trained counsellors available, and less likely in facilities located outside of Java-Bali and in facilities supporting a higher number of village midwives.

DISCUSSION

Despite targeted efforts by the Indonesian government and multinational agencies, significant gaps exist in the delivery of PMTCT that compromise the standard of care delivered in Indonesia. Future strategies should focus on improving the availability of tests and treatment, especially in the private sector and in rural areas.

The Cost-Effectiveness of HIV/STI Prevention in High-Income Countries with Concentrated Epidemic Settings: A Scoping Review

The purpose of this scoping review is to establish the state of the art on economic evaluations in the field of HIV/STI prevention in high-income countries with concentrated epidemic settings and to assess what we know about the cost-effectiveness of different measures. We reviewed economic evaluations of HIV/STI prevention measures published in the Web of Science and Cost-Effectiveness Registry databases. We included a total of 157 studies focusing on structural, behavioural, and biomedical interventions, covering a variety of contexts, target populations and approaches. The majority of studies are based on mathematical modelling and demonstrate that the preventive measures under scrutiny are cost-effective. Interventions targeted at high-risk populations yield the most favourable results. The generalisability and transferability of the study results are limited due to the heterogeneity of the populations, settings and methods involved. Furthermore, the results depend heavily on modelling assumptions. Since evidence is unequally distributed, we discuss implications for future research.

Cost-Effectiveness of HIV Retention and Re-engagement Interventions in High-Income Countries: A Systematic Literature Review

Engagement in lifelong HIV care is critical for both patient and public health, yet there are limited resources to invest in improving HIV outcomes. We systematically reviewed evidence on the cost-effectiveness of retention and re-engagement interventions. We searched five databases for peer-reviewed studies published between 2010 and 2020. We assessed reporting and methods quality, extracted data on target populations, interventions, and cost-effectiveness, and evaluated overall strength of evidence. Eleven studies met inclusion criteria, and eight had moderate-high quality. Cost-effectiveness estimates ranged from cost-saving to over $1,000,000/quality-adjusted life year (QALY) gained. Of the 73 cost-effectiveness ratios reported, 64% were < $100,000/QALY gained. Interventions were more likely to be cost-effective when targeted to high-risk groups, implemented in locations where baseline retention levels were low, and when used in combination with other high-impact HIV interventions (such as prevention). Overall, existing evidence is moderately strong that retention and/or re-engagement interventions can be cost-effective in high-income countries.

Understanding Individual Barriers to HIV Testing Among Undergraduate University Students: Results From a Cross-Sectional Study in Italy

Background

In Europe during 2019, just over half of those with HIV were diagnosed at a late stage of infection. Even though HIV testing is crucial for all strategies related to care, prevention and treatment of HIV/AIDS, we hypothesized that it is less practiced among university students, and, therefore, this study aimed to assess the uptake and factors associated with HIV testing in southern part of Italy.

Methods

A cross-sectional study was conducted from 1st to 31st July 2020 among undergraduate university students aged 18–29 years. Data were collected through an anonymous online questionnaire and included questions on socio-demographic and sexual history characteristics, knowledge and attitudes toward HIV infection, sexual and testing behaviors, and sources of information about HIV.

Findings

Among 1007 students, 41.5 and 54.7% knew that in Italy the test for early detection of HIV infection has not to be prescribed by a physician and that it is provided to anyone free of charge, respectively. Only 16.2% of the eligible students reported having ever tested for HIV and a very similar proportion (17.8%) was displayed among those who reported risky sexual behaviors. The multiple logistic regression analysis results indicated that the strongest predictor of HIV testing was attending medical or life sciences majors.

Interpretation

The uptake of HIV testing was low among Italian university students. Effective strategies to increase HIV testing and diagnoses have to aim at overarching individual barriers, such as lack of knowledge about information around the test itself.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The costs of scaling up HIV and syphilis testing in low- and middle-income countries: a systematic review

Around two-thirds of all new HIV infections and 90% of syphilis cases occur in low- and middle-income countries (LMICs). Testing is a key strategy for the prevention and treatment of HIV and syphilis. Decision-makers in LMICs face considerable uncertainties about the costs of scaling up HIV and syphilis testing. This paper synthesizes economic evidence on the costs of scaling up HIV and syphilis testing interventions in LMICs and evidence on how costs change with the scale of delivery. We systematically searched multiple databases (Medline, Econlit, Embase, EMCARE, CINAHL, Global Health and the NHS Economic Evaluation Database) for peer-reviewed studies examining the costs of scaling up HIV and syphilis testing in LMICs. Thirty-five eligible studies were identified from 4869 unique citations. Most studies were conducted in Sub-Saharan Africa (N = 17) and most explored the costs of rapid HIV in facilities targeted the general population (N = 19). Only two studies focused on syphilis testing. Seventeen studies were cost analyses, 17 were cost-effectiveness analyses and 1 was cost-benefit analysis of HIV or syphilis testing. Most studies took a modelling approach (N = 25) and assumed costs increased linearly with scale. Ten studies examined cost efficiencies associated with scale, most reporting short-run economies of scale. Important drivers of the costs of scaling up included testing uptake and the price of test kits. The 'true' cost of scaling up testing is likely to be masked by the use of short-term decision frameworks, linear unit-cost projections (i.e. multiplying an average cost by a factor reflecting activity at a larger scale) and availability of health system capacity and infrastructure to supervise and support scale up. Cost data need to be routinely collected alongside other monitoring indicators as HIV and syphilis testing continues to be scaled up in LMICs.

Economic evaluation of point-of-care testing and treatment for sexually transmitted and genital infections in pregnancy in low- and middle-income countries: A systematic review

BACKGROUND

Sexually transmitted and genital infections in pregnancy are associated with adverse pregnancy and birth outcomes. Point-of-care tests for these infections facilitate testing and treatment in a single antenatal clinic visit and may reduce the risk of adverse outcomes. Successful implementation and scale-up depends on understanding comparative effectiveness of such programmes and their comparative costs and cost effectiveness. This systematic review synthesises and appraises evidence from economic evaluations of point-of-care testing and treatment for sexually transmitted and genital infections among pregnant women in low- and middle-income countries.

METHODS

Medline, Embase and Web of Science databases were comprehensively searched using pre-determined criteria. Additional literature was identified by searching Google Scholar and the bibliographies of all included studies. Economic evaluations were eligible if they were set in low- and middle-income countries and assessed antenatal point-of-care testing and treatment for syphilis, chlamydia, gonorrhoea, trichomoniasis, and/or bacterial vaginosis. Studies were analysed using narrative synthesis. Methodological and reporting standards were assessed using two published checklists.

RESULTS

Sixteen economic evaluations were included in this review; ten based in Africa, three in Latin and South America and three were cross-continent comparisons. Fifteen studies assessed point-of-care testing and treatment for syphilis, while one evaluated chlamydia. Key drivers of cost and cost-effectiveness included disease prevalence; test, treatment, and staff costs; test sensitivity and specificity; and screening and treatment coverage. All studies met 75% or more of the criteria of the Drummond Checklist and 60% of the Consolidated Health Economics Evaluation Reporting Standards.

CONCLUSIONS

Generally, point-of-care testing and treatment was cost-effective compared to no screening, syndromic management, and laboratory-based testing. Future economic evaluations should consider other common infections, and their lifetime impact on mothers and babies. Complementary affordability and equity analyses would strengthen the case for greater investment in antenatal point-of-care testing and treatment for sexually transmitted and genital infections.

The role of artificial intelligence in healthcare: a structured literature review

BACKGROUND/INTRODUCTION

Artificial intelligence (AI) in the healthcare sector is receiving attention from researchers and health professionals. Few previous studies have investigated this topic from a multi-disciplinary perspective, including accounting, business and management, decision sciences and health professions.

METHODS

The structured literature review with its reliable and replicable research protocol allowed the researchers to extract 288 peer-reviewed papers from Scopus. The authors used qualitative and quantitative variables to analyse authors, journals, keywords, and collaboration networks among researchers. Additionally, the paper benefited from the Bibliometrix R software package.

RESULTS

The investigation showed that the literature in this field is emerging. It focuses on health services management, predictive medicine, patient data and diagnostics, and clinical decision-making. The United States, China, and the United Kingdom contributed the highest number of studies. Keyword analysis revealed that AI can support physicians in making a diagnosis, predicting the spread of diseases and customising treatment paths.

CONCLUSIONS

The literature reveals several AI applications for health services and a stream of research that has not fully been covered. For instance, AI projects require skills and data quality awareness for data-intensive analysis and knowledge-based management. Insights can help researchers and health professionals understand and address future research on AI in the healthcare field.

Evaluation and Management of the Infant Exposed to HIV in the United States

Pediatricians play a crucial role in optimizing the prevention of perinatal transmission of HIV infection. Pediatricians provide antiretroviral prophylaxis to infants born to women with HIV type 1 (HIV) infection during pregnancy and to those whose mother's status was first identified during labor or delivery. Infants whose mothers have an undetermined HIV status should be tested for HIV infection within the boundaries of state laws and receive presumptive HIV therapy if the results are positive. Pediatricians promote avoidance of postnatal HIV transmission by advising mothers with HIV not to breastfeed. Pediatricians test the infant exposed to HIV for determination of HIV infection and monitor possible short- and long-term toxicity from antiretroviral exposure. Finally, pediatricians support families living with HIV by providing counseling to parents or caregivers as an important component of care.

HIV testing among pregnant women with prenatal care in the United States: An analysis of the 2011-2017 National Survey of Family Growth

Although there has been significant progress in reducing perinatal human immunodeficiency virus (HIV) transmission, the United States is yet to meet the proposed elimination goal of less than one infection per 100,000 live births. Failure to screen all pregnant women for HIV as recommended by the Centers for Disease Control and Prevention can result in missed opportunities for preventing vertical transmission of HIV with antiretroviral drugs. Using the 2011-2017 National Survey of Family Growth, this study examined HIV testing among pregnant women during prenatal care. We estimated the weighted proportion of self-reported HIV testing among women whose last pregnancy ended within 12 months prior to the interview. Logistic regression models were used to determine the factors associated with HIV testing. Of the 1566 women included in the study, 76.4% (95% confidence intervals [CI] = 72.8-80.0) reported receiving an HIV test during prenatal care. In the multivariable regression model, high school diploma (adjusted odds ratio [aOR] = 1.9, 95% CI = 1.1-3.1), two completed pregnancies (aOR = 1.7, 95% CI = 1.1-2.7), health insurance coverage in the last 12 months (aOR = 1.6, 95% CI = 1.0-2.6), Hispanic race/ethnicity (aOR = 2.8, 95% CI = 1.8-4.4), and non-Hispanic black race/ethnicity (aOR = 2.2, 95% CI = 1.3-3.8) were associated with higher odds of reporting being tested for HIV. However, household income of 300% or more of the federal poverty level (aOR = 0.6, 95% CI = 0.3-0.9) and urban residence (aOR = 0.5, 95% CI = 0.3-0.9) were associated with lower odds of reporting HIV testing. These findings suggest that HIV testing among pregnant women during prenatal care is not universal and may affect achieving the goal of elimination of mother-to-child transmission of HIV in the United States.

HIV testing during pregnancy for prevention of mother-to-child transmission of HIV in Ethiopia

INTRODUCTION

HIV testing during pregnancy provides an entry point to prevention of mother-to-child transmission of HIV and to access treatment for HIV positive women. The study aimed to assess the uptake of HIV testing during pregnancy and associated factors among Ethiopian women.

METHODS

We analyzed the 2016 Ethiopian Demographic and Health Survey dataset. Women who gave birth within one year prior to the survey were included in the analysis. Uptake of HIV testing during pregnancy is defined as receiving HIV testing service during pregnancy and/or at the time of delivery and knew the test results. Adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs) were calculated by using step-wise backward logistic regression analyses to identify factors associated with HIV testing during pregnancy.

RESULTS

A total of 2114 women who were pregnant in the last one year prior to the survey were included in the analysis. Of these, only 35.1% were tested for HIV and received the test results during pregnancy. About one third of women who had antenatal care follow-up missed the opportunity to be tested for HIV. Compared to women who had no formal education, those who had primary level education (AOR = 1.55; 95% CI: 1.12-2.15), secondary level education (AOR = 2.56 95%CI: 1.36-3.82), or higher education (AOR = 3.95, 95%CI: 1.31-11.95) were more likely to be tested for HIV during pregnancy. Similarly, having awareness about mother-to-child transmission of HIV (AOR = 2.03, 95%CI: 1.48-2.78), and living in urban areas (AOR = 3.30, 95%CI: 1.39-7.85) were positively and independently associated with uptake of HIV during pregnancy. Women who have stigmatizing attitude towards HIV positive people were less likely to be tested for HIV (AOR = 0.57, 95%CI: 0.40-0.79).

CONCLUSION

Uptake of HIV testing during pregnancy is low. Missed opportunity among women who had antenatal care visits was very high. Integrating HIV testing with antenatal care services, improving HIV testing service quality and access are essential to increase uptake of HIV testing during pregnancy and reach the goal of eliminating MTCT.