Cost-effectiveness of elective cesarean delivery in human immunodeficiency virus-infected women(1)

An overview of the health economic implications of elective caesarean section

The caesarean section rate has continued to increase in most industrialised countries, which raises a number of economic concerns. This review provides an overview of the health economic implications of elective caesarean section. It provides a succinct summary of the health consequences associated with elective caesarean section for both the infant and the mother over the perinatal period and beyond. It highlights factors that complicate our understanding of the health consequences of elective caesarean section, including inconsistencies in definitions and coding of the procedure, failure to adopt an intention-to-treat principle when drawing comparisons, and the widespread reliance on observational data. The paper then summarises the economic costs associated with elective caesarean section. Evidence is presented to suggest that planned caesarean section may be less costly than planned vaginal birth in some clinical contexts, for example where the singleton fetus lies in a breech position at term. In contrast, elective caesarean section (or caesarean section as a whole) appears to be more costly than vaginal delivery (either spontaneous or instrumented) in low-risk or unselected populations. The paper proceeds with an overview of economic evaluations associated with elective caesarean section. All are currently based on decision-analytic models. Evidence is presented to suggest that planned trial of labour (attempted vaginal birth) following a previous caesarean section appears to be a more cost-effective option than elective caesarean section, although its cost effectiveness is dependent upon the probability of successful vaginal delivery. There is conflicting evidence on the cost effectiveness of maternal request caesareans when compared with trial of labour. The paucity of evidence on the value pregnant women, clinicians and other groups in society place on the option of elective caesarean section is highlighted. Techniques that might be used to elicit preferences for elective caesarean section and its attributes are outlined. The review concludes with directions for future research in this area.

Early infant HIV-1 diagnosis programs in resource-limited settings: opportunities for improved outcomes and more cost-effective interventions

Early infant diagnosis (EID) of HIV-1 infection confers substantial benefits to HIV-infected and HIV-uninfected infants, to their families, and to programs providing prevention of mother-to-child transmission (PMTCT) services, but has been challenging to implement in resource-limited settings. In order to correctly inform parents/caregivers of infant infection status and link HIV-infected infants to care and treatment, a 'cascade' of events must successfully occur. A frequently cited barrier to expansion of EID programs is the cost of the required laboratory assays. However, substantial implementation barriers, as well as personnel and infrastructure requirements, exist at each step in the cascade. In this update, we review challenges to uptake at each step in the EID cascade, highlighting that even with the highest reported levels of uptake, nearly half of HIV-infected infants may not complete the cascade successfully. We next synthesize the available literature about the costs and cost effectiveness of EID programs; identify areas for future research; and place these findings within the context of the benefits and challenges to EID implementation in resource-limited settings.

The cost-effectiveness of directly observed highly-active antiretroviral therapy in the third trimester in HIV-infected pregnant women

BACKGROUND

In HIV-infected pregnant women, viral suppression prevents mother-to-child HIV transmission. Directly observed highly-active antiretroviral therapy (HAART) enhances virological suppression, and could prevent transmission. Our objective was to project the effectiveness and cost-effectiveness of directly observed administration of antiretroviral drugs in pregnancy.

METHODS AND FINDINGS

A mathematical model was created to simulate cohorts of one million asymptomatic HIV-infected pregnant women on HAART, with women randomly assigned self-administered or directly observed antiretroviral therapy (DOT), or no HAART, in a series of Monte Carlo simulations. Our primary outcome was the quality-adjusted life expectancy in years (QALY) of infants born to HIV-infected women, with the rates of Caesarean section and HIV-transmission after DOT use as intermediate outcomes. Both self-administered HAART and DOT were associated with decreased costs and increased life-expectancy relative to no HAART. The use of DOT was associated with a relative risk of HIV transmission of 0.39 relative to conventional HAART; was highly cost-effective in the cohort as a whole (cost-utility ratio $14,233 per QALY); and was cost-saving in women whose viral loads on self-administered HAART would have exceeded 1000 copies/ml. Results were stable in wide-ranging sensitivity analyses, with directly observed therapy cost-saving or highly cost-effective in almost all cases.

CONCLUSIONS

Based on the best available data, programs that optimize adherence to HAART through direct observation in pregnancy have the potential to diminish mother-to-child HIV transmission in a highly cost-effective manner. Targeted use of DOT in pregnant women with high viral loads, who could otherwise receive self-administered HAART would be a cost-saving intervention. These projections should be tested with randomized clinical trials.

Cesarean delivery for HIV-infected women: recommendations and controversies

Two studies that were published in 1999 demonstrated that cesarean delivery before labor and before the rupture of membranes (elective cesarean delivery) reduces the risk of mother-to-child transmission of the human immunodeficiency virus (HIV). On the basis of these results, the American College of Obstetricians and Gynecologists and the US Public Health Service recommend that HIV-infected pregnant women with plasma viral loads of >1000 copies per milliliter be counseled regarding the benefits of elective cesarean delivery. Since the release of these guidelines, the cesarean delivery rate among HIV-infected women in the United States has increased dramatically. Major postpartum morbidity is uncommon, and cesarean delivery among HIV-infected women is relatively safe and cost-effective. However, a number of important questions remain unanswered, including whether cesarean delivery has a role among HIV-infected women with low plasma viral loads or who receive combination antiretroviral regimens.

Rapid HIV versus enzyme-linked immunosorbent assay screening in a low-risk Mexican American population presenting in labor: a cost-effectiveness analysis

OBJECTIVE

Mother-to-child transmission of human immunodeficiency virus is the most common cause of pediatric human immunodeficiency virus in the United States; the Centers for Disease Control and Prevention recommendations endorse rapid human immunodeficiency virus testing for women with unknown viral status to quicken antiretroviral therapy. We compared the cost-effectiveness of Oraquick (Orasure Technologies, Bethlehem, Pa) rapid testing versus enzyme-linked immunosorbent assay testing for a low-risk population of Mexican American women who are in labor.

STUDY DESIGN

Using decision analysis techniques, we tested 2 strategies: (1) testing with enzyme-linked immunosorbent assay that was confirmed by Western blot and (2) testing with Oraquick rapid testing that was confirmed by Western blot. All seropositive parturients received zidovudine treatment in labor. The baseline assumptions were the incidence of human immunodeficiency virus in Mexican American mothers (0.05%), mother-to-child transmission with no treatment (25%), with treatment in labor (10%), sensitivity of enzyme-linked immunosorbent assay (98%), positive predictive value of enzyme-linked immunosorbent assay (10%), sensitivity/specificity of Oraquick rapid testing (99%/100%), positive predictive value of Oraquick rapid testing (83%-100%), sensitivity/specificity of Western blot (97%/99%), costs (enzyme-linked immunosorbent assay [dollar 5], Oraquick rapid testing [dollar 15], Western blot [dollar 25], zidovudine treatment [dollar 76] for 12 hours labor, neonatal treatment [dollar 2.50], lifetime treatment of human immunodeficiency virus-affected child [dollar 194,250]). Sensitivity analyses were done over a wide range of assumptions that included the costs of tests, the sensitivity of Oraquick rapid testing, the positive predictive value of enzyme-linked immunosorbent assay and Oraquick rapid testing, and the costs of treatments.

RESULTS

Oraquick rapid testing was the preferred strategy at dollar 98 spent per human immunodeficiency virus-negative child versus dollar 491 for enzyme-linked immunosorbent assay testing. Much of the cost of the enzyme-linked immunosorbent assay strategy was due to the treatment of women and infants with false-positive tests. Sensitivity analysis over test costs, test sensitivity, and other variables found the analysis results to be robust. Threshold analysis revealed that, if the cost remained < dollar 409.90, Oraquick rapid testing was the dominant test.

CONCLUSION

In a low prevalence population, the universal use of Oraquick rapid testing is cost-effective because of the low rate of false-positive results, thus preventing the emotional and economic costs of unnecessary treatment for human immunodeficiency virus to the new mother and her family.

Economic implications of method of delivery

OBJECTIVE

This study was undertaken to examine the costs of hospital care associated with different methods of delivery.

STUDY DESIGN

An 18-year population-based cohort study (1985-2002) using the Nova Scotia Atlee Perinatal Database compared outcomes in nulliparous women at term undergoing spontaneous or induced labor for planned vaginal delivery, or undergoing cesarean delivery without labor. Costs that were assessed included physician fees, nursing hours in the labor and delivery, postpartum and neonatal intensive care units, epidural use, induction of labor agents, and consumables.

RESULTS

A total of 27,614 pregnancies satisfied inclusion and exclusion criteria, 5233 of which had labor induced. A comparison of mean costs per mother/infant pair demonstrated that cesarean delivery in labor ($2137) was increased compared with spontaneous vaginal delivery ($1340, P=.01), assisted vaginal delivery ($1594, P=.01), and cesarean delivery without labor ($1532, P=.01). The cost of delivery after induction of labor ($1715) was increased compared with spontaneous onset of labor ($1474, P<.001).

CONCLUSION

Cesarean delivery in labor occurs more frequently with labor induction and is associated with increased costs compared with other methods of delivery.

Trends in interventions to reduce perinatal human immunodeficiency virus type 1 transmission in North Carolina

BACKGROUND

Mother-to-child transmission of HIV has decreased in industrialized countries because of widespread use of antiretroviral therapy (ART) by HIV-infected pregnant women and perhaps to increased use of elective cesarean section. We evaluated changes in the use of ART and mode of delivery among HIV positive pregnant women in North Carolina.

METHODS

We reviewed the medical records of HIV-exposed infants born in North Carolina between January 1, 1998, and December 31, 1999, who were tested for HIV DNA. These results were compared with data collected on HIV-exposed infants born from 1993 through 1997.

RESULTS

The use of combination ART increased from 1.5% in 1996 to 73% in 1999. The most common ART was zidovudine/lamivudine (39%) followed by zidovudine-lamivudine-nelfinavir (34%), although 34 combinations were used. Elective cesarean sections in the state increased significantly from 16.5% in the first half of 1998 to 49.4% in the second half of 1999. Overall transmission rates declined from 24.5% in 1993 to an average of 10.6% in 1994 to 1996 (41 of 385) and to 3.5% in 1997 to 1999 (15 of 428).

CONCLUSIONS

Increased use of combination ART and elective cesarean section was accompanied by consistently low rates of perinatal transmission. However, because perinatal transmission rates were also low among women who used combination therapy and had vaginal deliveries, it is difficult to determine how much additional benefit cesarean section affords. Most HIV transmission occurred among women who lacked prenatal care and did not receive or adhere to ART.