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Boachie MK, Bhardwaj V, Mamabolo B, Mdewa W, Goldstein S, Hofman K, Thsehla E. Economic Evaluation of Free Prevention of Mother-to-Child Transmissions (PMTCT) Services to Non-South African Women Living in South Africa. Health Serv Insights 2025; 18:11786329251316660. [PMID: 39959139 PMCID: PMC11826849 DOI: 10.1177/11786329251316660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2024] [Accepted: 01/14/2025] [Indexed: 02/18/2025] Open
Abstract
Approximately 1.33 million pregnancies are recorded in South Africa annually. About 30% of all pregnant women are HIV positive, posing a serious risk to unborn children. However, effective interventions such as prevention of mother-to-child transmissions (PMTCT) services have been shown to significantly reduce the risk of mother-to-child or vertical transmission. Migrant women in South Africa face challenges in accessing [free] healthcare services. This study aims to assess the cost-effectiveness of providing free PMTCT services to migrant women living in South Africa. We employed cost-effectiveness analysis methodology to establish the cost and outcomes (averted pediatric infections and averted disability-adjusted life years (DALYs)) associated with free PMTCT services for migrant women. The comparator was provision of only antenatal care (ANC) while the intervention was ANC + PMTCT services. A Microsoft Excel-based decision tree model was designed to achieve the study objectives. Data on costs and health outcomes for each intervention was sourced from the literature on HIV/AIDS. The prevalence-based study is conducted from a public sector healthcare payer perspective. Provision of ANC + PMTCT services to migrants will prevent 14 562 new infections among 52 762 HIV positive pregnant women. The estimated total expected cost of ANC + PMTCT service was US$52 889 per 1000 live births compared to US$191 000 for ANC only per 1000 live births. The expected cost for the do-nothing scenario was US$73 535 per 1000 live births. The expected health benefit (ie, averted DALYs) associated with do-nothing scenario, ANC, and ANC + PMTCT were 277, 265 and 76 DALYs, respectively. ANC + PMTCT service provision produces the lowest DALYs at lower cost thereby producing cost-saving of US$733/DALY averted per 1000 live births. Further, an average of US$1.5 million would be required annually to achieve 100% coverage of HIV+ migrant women. Therefore, provision of ANC and PMTCT services to migrant women is cost-effective when compared to not offering PMTCT services and allows the government to avoid the long-term cost of antiretroviral therapy (ART) provision.
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Affiliation(s)
- Micheal Kofi Boachie
- SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, School of Public Health, Faculty of Health Sciences, Wits University, Johannesburg, South Africa
| | - Vinayak Bhardwaj
- SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, School of Public Health, Faculty of Health Sciences, Wits University, Johannesburg, South Africa
| | - Bontle Mamabolo
- SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, School of Public Health, Faculty of Health Sciences, Wits University, Johannesburg, South Africa
| | - Winfrida Mdewa
- SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, School of Public Health, Faculty of Health Sciences, Wits University, Johannesburg, South Africa
| | - Susan Goldstein
- SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, School of Public Health, Faculty of Health Sciences, Wits University, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, School of Public Health, Faculty of Health Sciences, Wits University, Johannesburg, South Africa
| | - Evelyn Thsehla
- SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, School of Public Health, Faculty of Health Sciences, Wits University, Johannesburg, South Africa
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Patrikar S, Bhardwaj M, Dudeja P, Kunte R. Cost-effectiveness of the prevention of parent-to-child transmission guidelines of HIV in India. Med J Armed Forces India 2024; 80:301-306. [PMID: 38800004 PMCID: PMC11116979 DOI: 10.1016/j.mjafi.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/07/2022] [Indexed: 11/19/2022] Open
Abstract
Background One of the modes of transmission of HIV infection in India is from mother-to-child. In 2014, Prevention of Parent-to-child Transmission (PPTCT) guidelines of HIV in India were implemented which included shifting from Option A to Option B and B+. The aim of the present study was to evaluate health and cost related outcomes after implementation of these new guidelines. Methods A decision analytical model was used to compare the PPTCT Option A with the new WHO Option of B and B+. Transmissions in serodiscordant couples and infants at 18 months were considered as health outcomes. The estimation of the cost for PPTCT services and HIV treatment was done using Costing Tool for Elimination Initiatives (CTEI) developed by National Center for Global Health and Medicine (NCGM). Results The reduction in transmission rates in HIV infants was 33%. In serodiscordant couples the reduction in risk of HIV transmission from Option A to Option B and B+ was 72% and 87%, respectively. The incremental cost-effectiveness ratio (ICER) per quality adjusted life years (QALY) gained by averting infant infection, and for both infant and partner was US$ 238 and US$ 181 for Option B and US$ 1265 and US$ 947 for Option B+, respectively. Conclusion It was found that Options B and B+ are more cost-effective as compared to option A. This effectiveness further increases when prevention of partner infections in Option B and B+ is taken into account.
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Affiliation(s)
- Seema Patrikar
- Senior Lecturer in Statistics & Demography, Department of Community Medicine, Armed Forces Medical College, Pune, India
| | - Meenakshi Bhardwaj
- Professor (AIHPP), Department of Obst & Gynae, Armed Forces Medical College, Pune, India
| | - Puja Dudeja
- Director MS (PS), Office of DGMS (Army), New Delhi, India
| | - Renuka Kunte
- PMO, Headquarter Maintenance Command, Air Force Nagpur, India
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Shepard DS, Halasa-Rappel YA, Rowlands KR, Kulchyckyj M, Basaza RK, Otieno ED, Mutatina B, Kariuki S, Musange SF. Economic analysis of a new four-panel rapid screening test in antenatal care in Kenya, Rwanda, and Uganda. BMC Health Serv Res 2023; 23:815. [PMID: 37525192 PMCID: PMC10391856 DOI: 10.1186/s12913-023-09775-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 07/03/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND We performed an economic analysis of a new technology used in antenatal care (ANC) clinics, the ANC panel. Introduced in 2019-2020 in five Rwandan districts, the ANC panel screens for four infections [hepatitis B virus (HBV), human immunodeficiency virus (HIV), malaria, and syphilis] using blood from a single fingerstick. It increases the scope and sensitivity of screening over conventional testing. METHODS We developed and applied an Excel-based economic and epidemiologic model to perform cost-effectiveness and cost-benefit analyses of this technology in Kenya, Rwanda, and Uganda. Costs include the ANC panel itself, its administration, and follow-up treatment. Effectiveness models predicted impacts on maternal and infant mortality and other outcomes. Key parameters are the baseline prevalence of each infection and the effectiveness of early treatment using observations from the Rwanda pilot, national and international literature, and expert opinion. For each parameter, we found the best estimate (with 95% confidence bound). RESULTS The ANC panel averted 92 (69-115) disability-adjusted life years (DALYs) per 1,000 pregnant women in ANC in Kenya, 54 (52-57) in Rwanda, and 258 (156-360) in Uganda. Net healthcare costs per woman ranged from $0.53 ($0.02-$4.21) in Kenya, $1.77 ($1.23-$5.60) in Rwanda, and negative $5.01 (-$6.45 to $0.48) in Uganda. Incremental cost-effectiveness ratios (ICERs) in dollars per DALY averted were $5.76 (-$3.50-$11.13) in Kenya, $32.62 ($17.54-$46.70) in Rwanda, and negative $19.40 (-$24.18 to -$15.42) in Uganda. Benefit-cost ratios were $17.48 ($15.90-$23.71) in Kenya, $6.20 ($5.91-$6.45) in Rwanda, and $25.36 ($16.88-$33.14) in Uganda. All results appear very favorable and cost-saving in Uganda. CONCLUSION Though subject to uncertainty, even our lowest estimates were still favorable. By combining field data and literature, the ANC model could be applied to other countries.
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Affiliation(s)
- Donald S Shepard
- The Heller School for Social Policy & Management, Brandeis University, Waltham, MA, 02454-9110, USA.
| | - Yara A Halasa-Rappel
- The Heller School for Social Policy & Management, Brandeis University, Waltham, MA, 02454-9110, USA
- Commonwealth Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Katharine R Rowlands
- The Heller School for Social Policy & Management, Brandeis University, Waltham, MA, 02454-9110, USA
| | - Maria Kulchyckyj
- The Heller School for Social Policy & Management, Brandeis University, Waltham, MA, 02454-9110, USA
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Masiano SP, Kawende B, Ravelomanana NLR, Green TL, Dahman B, Thirumurthy H, Kimmel AD, Yotebieng M. Economic costs and cost-effectiveness of conditional cash transfers for the uptake of services for the prevention of vertical HIV transmissions in a resource-limited setting. Soc Sci Med 2023; 320:115684. [PMID: 36696797 PMCID: PMC9975037 DOI: 10.1016/j.socscimed.2023.115684] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 12/06/2022] [Accepted: 01/13/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Prevention of mother-to-child transmission (PMTCT) is critical for halting the HIV epidemic. However, innovative approaches to improve PMTCT uptake may be resource-intensive. We examined the economic costs and cost-effectiveness of conditional cash transfers (CCTs) for the uptake of PMTCT services in the Democratic Republic of Congo. METHODS We leveraged data from a randomized controlled trial of CCTs (n = 216) versus standard PMTCT care alone (standard of care (SOC), n = 217). Economic cost data came from multiple sources, with costs analyzed from the societal perspective and reported in 2016 international dollars (I$). Effectiveness outcomes included PMTCT uptake (i.e., accepting all PMTCT visits and services) and retention (i.e., in HIV care at six weeks post-partum). Generalized estimating equations estimated effectiveness (relative risk) and incremental costs, with incremental effectiveness reported as the number of women needing CCTs for an additional PMTCT uptake or retention. We evaluated the cost-effectiveness of the CCTs at various levels of willingness-to-pay and assessed uncertainty using deterministic sensitivity analysis and cost-effectiveness acceptability curves. RESULTS Mean costs per participant were I$516 (CCTs) and I$431 (SOC), representing an incremental cost of I$85 (95% CI: 59, 111). PMTCT uptake was more likely for CCTs vs SOC (68% vs 53%, p < 0.05), with seven women needing CCTs for each additional PMTCT service uptake; twelve women needed CCTs for an additional PMTCT retention. The incremental cost-effectiveness of CCTs vs SOC was I$595 (95% CI: I$550, I$638) for PMTCT uptake and I$1028 (95% CI: I$931, I$1125) for PMTCT retention. CCTs would be an efficient use of resources if society's willingness-to-pay for an additional woman who takes up PMTCT services is at least I$640. In the worst-case scenario, the findings remained relatively robust. CONCLUSIONS Given the relatively low cost of the CCTs, policies supporting CCTs may decrease onward HIV transmission and expedite progress toward ending the epidemic.
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Affiliation(s)
- Steven P Masiano
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
| | - Bienvenu Kawende
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of the Congo, The
| | - Noro Lantoniaina Rosa Ravelomanana
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of the Congo, The; Albert Einstein College of Medicine, Department of Medicine, Division of General Internal Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
| | - Tiffany L Green
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA; Departments of Population Health Sciences and Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA
| | - Harsha Thirumurthy
- Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, USA; Center for Health Incentives and Behavioral Economics, University of Pennsylvania, USA
| | - April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA.
| | - Marcel Yotebieng
- The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of the Congo, The; Albert Einstein College of Medicine, Department of Medicine, Division of General Internal Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
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Qu SL, Wang AL, Yin HM, Deng JQ, Wang XY, Yang YH, Pan XP, Zhang T. Cost-effectiveness analysis of the prevention of mother-to-child transmission of HIV. Infect Dis Poverty 2022; 11:68. [PMID: 35706049 PMCID: PMC9202156 DOI: 10.1186/s40249-022-00983-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 05/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The number of HIV-positive pregnant women accounted for about 10% of China's total over the past few years in Liangshan Prefecture, Sichuan province in China. Although cost-effectiveness of the PMTCT of HIV have been evaluated in other previous studies, no specific study has been conducted in Liangshan prefecture, nor has the expenses paid individually by HIV-positive pregnant women been included. The purpose of this study was to evaluate both the short-term and long-term cost-effectiveness of PMTCT of HIV in Liangshan Prefecture from the social perspective. METHODS From December 2018 to January 2019, individual expenses and the other costs were collected: individual expenses of 133 recruited HIV-positive pregnant women registered in the National Information System of Prevention of Mother-to-Child Transmission of HIV, Syphilis, and HBV, and the other costs from local maternal and child healthcare hospitals, Centers for Disease Control and Prevention, and general hospitals. The costs, the number of pediatric infections averted from being HIV infected were analyzed. And, Life years gained by pediatric infections averted were calculated by using a life table. Besides, Direct benefit was calculated through a Markov mode. Furthermore, One-way sensitivity analysis was conducted for key variables affecting the benefit-cost ratio. RESULTS The estimated number of pediatric infections averted was 164.The total cost was USD 114.1 million, including direct medical costs, direct non-medical costs, and indirect costs, which were USD 54.2 million, USD 53.4 million, and USD 6.5 million, respectively. 630.6 person-years discounted to 2017 were gained at a 3% annual rate, and cost per life year gained was USD 1809.50. Direct benefits were USD 198.4 million, indirect benefits USD 82.5 million, and the benefit-cost ratio was 1.5. The sensitivity analysis showed that if PMTCT costs hypothetically ranged from USD 85.6 million to USD 142.6 million, benefit-cost ratio would vary from 1.0 to 2.3. CONCLUSIONS PMTCT of HIV in Liangshan Prefecture was very cost-effective. It was a great economic burden of PMTCT on HIV-positive pregnant women and their families to take individual expenses. Therefore, it could be suggested that individual expenses should be covered as much as possible by different types of financing.
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Affiliation(s)
- Shui-Ling Qu
- Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China.,National Center for Women and Children's Health, Chinese Center for Disease Control and Prevention, No. 12 Dahuisi Road, Haidian District, Beijing, 100081, China
| | - Ai-Ling Wang
- National Center for Women and Children's Health, Chinese Center for Disease Control and Prevention, No. 12 Dahuisi Road, Haidian District, Beijing, 100081, China.
| | - Hong-Mei Yin
- Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China
| | - Jin-Qi Deng
- Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China
| | - Xiao-Yan Wang
- National Center for Women and Children's Health, Chinese Center for Disease Control and Prevention, No. 12 Dahuisi Road, Haidian District, Beijing, 100081, China
| | - Ye-Huan Yang
- National Center for Women and Children's Health, Chinese Center for Disease Control and Prevention, No. 12 Dahuisi Road, Haidian District, Beijing, 100081, China
| | - Xiao-Ping Pan
- National Center for Women and Children's Health, Chinese Center for Disease Control and Prevention, No. 12 Dahuisi Road, Haidian District, Beijing, 100081, China
| | - Tong Zhang
- Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, China.
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Naburi HE, Mujinja P, Kilewo C, Biberfeld G, Bärnighausen T, Manji K, Lyatuu G, Urrio R, Zethraeus N, Orsini N, Ekström AM. Health care costs associated with clinic visits for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania. Medicine (Baltimore) 2021; 100:e27828. [PMID: 34797311 PMCID: PMC8601283 DOI: 10.1097/md.0000000000027828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/28/2021] [Indexed: 01/05/2023] Open
Abstract
Early and appropriate antenatal care (ANC) is key for the effectiveness of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). We evaluated the importance of ANC visits and related service costs for women receiving option B+ to prevent mother-to-child transmission (MTCT) of HIV in Tanzania.A cost analysis from a health care sector perspective was conducted using routine data of 2224 pregnant women newly diagnosed with HIV who gave birth between August 2014 and May 2016 in Dar es Salaam, Tanzania. We evaluated risk of infant HIV infection at 12 weeks postnatally in relation to ANC visits (<4 vs ≥4 visits). Costs for service utilisation were estimated through empirical observations and the World Health Organisation Global Price Reporting Mechanism.Mean gestational age at first ANC visit was 22 (±7) weeks. The average number of ANC/prevention of MTCT visits among the 2224 pregnant women in our sample was 3.6 (95% confidence interval [CI] 3.6-3.7), and 57.3% made ≥4 visits. At 12 weeks postnatally, 2.7% (95% CI 2.2-3.6) of HIV exposed infants had been infected. The risk of MTCT decreased with the number of ANC visits: 4.8% (95% CI 3.6-6.4) if the mother had <4 visits, and 1.0% (95% CI 0.5-1.7) at ≥4. The adjusted MTCT rates decreased by 51% (odds ratio 0.49, 95% CI 0.31-0.77) for each additional ANC visit made. The potential cost-saving was 2.2 US$ per woman at ≥4 visits (84.8 US$) compared to <4 visits (87.0 US$), mainly due to less defaulter tracing.Most pregnant women living with HIV in Dar es Salaam initiated ANC late and >40% failed to adhere to the recommended minimum of 4 visits. Improved ANC attendance would likely lead to fewer HIV-infected infants and reduce both short and long-term health care costs due to less spending on defaulter tracing and future treatment costs for the children.
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Affiliation(s)
- Helga Elineema Naburi
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Phares Mujinja
- Institute of Public health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Charles Kilewo
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
| | - Gunnel Biberfeld
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
- Africa Health Research Institute (AHRI), Mtubatuba, South Africa
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Goodluck Lyatuu
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
- Management and Development for Health (MDH), Dar es Salaam, Tanzania
| | - Roseline Urrio
- Departments of Obstetrics and Gynaecology, MUHAS, Dar es Salaam, Tanzania
- Management and Development for Health (MDH), Dar es Salaam, Tanzania
| | - Niklas Zethraeus
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Milanzi E, Mwapasa V, Joseph J, Jousset A, Tchereni T, Gunda A, Phiri J, Reece JC. Receipt of infant HIV DNA PCR test results is associated with a reduction in retention of HIV-exposed infants in integrated HIV care and healthcare services: a quantitative sub-study nested within a cluster randomised trial in rural Malawi. BMC Public Health 2020; 20:1879. [PMID: 33287772 PMCID: PMC7720620 DOI: 10.1186/s12889-020-09973-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 11/25/2020] [Indexed: 11/29/2022] Open
Abstract
Background Retention of HIV-infected mothers in integrated HIV and healthcare facilities is effective at reducing mother-to-child-transmission (MTCT) of HIV. In the context of Option B+, we examined maternal and HIV-exposed infant retention across three study arms to 18 months postpartum: mother-and-infant clinics (MIP), MIP with short-messaging service (MIP + SMS) and standard of care (SOC). In particular, we focused on the impact of mothers receiving an infant’s HIV PCR test result on maternal and infant study retention. Methods A quantitative sub-study nested within a cluster randomised trial undertaken between May 2013 and August 2016 across 30 healthcare facilities in rural Malawi enrolling HIV-infected pregnant mothers and HIV-exposed infants on delivery, was performed. Survival probabilities of maternal and HIV-exposed infant study retention was estimated using Kaplan-Meier curves. Associations between mother’s receiving an infant’s HIV test result and in particular, an infant’s HIV-positive result on maternal and infant study retention were modelled using time-varying multivariate Cox regression. Results Four hundred sixty-one, 493, and 396 HIV-infected women and 386, 399, and 300 HIV-exposed infants were enrolled across study arms; MIP, MIP + SMS and SOC, respectively. A total of 47.5% of mothers received their infant’s HIV test results < 5 months postpartum. Receiving an infant’s HIV result by mothers was associated with a 70% increase in infant non-retention in the study compared with not receiving an infant’s result (HR = 1.70; P-value< 0.001). Receiving a HIV-positive result was associated with 3.12 times reduced infant retention compared with a HIV-negative result (P-value< 0.001). Of the infants with a HIV-negative test result, 87% were breastfed at their final study follow-up. Conclusions Receiving an infant’s HIV test result was a driving factor for reduced infant study retention, especially an infant’s HIV-positive test result. As most HIV-negative infants were still breastfed at their last follow-up, this indicates a large proportion of HIV-exposed infants were potentially at future risk of MTCT of HIV via breastfeeding but were unlikely to undergo follow-up HIV testing after breastfeeding cessation. Future studies to identify and address underlying factors associated with infant HIV testing and reduced infant retention could potentially improve infant retention in HIV/healthcare facilities. Trial registration Pan African Clinical Trial Registry: PACTR201312000678196. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-020-09973-y.
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Affiliation(s)
- Elasma Milanzi
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia.,Victorian Centre for Biostatistics, Melbourne, Victoria, Australia
| | - Victor Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jessica Joseph
- Clinton Health Access Initiative (CHAI), MA, Boston, USA
| | | | | | - Andrews Gunda
- Clinton Health Access Initiative (CHAI), Lilongwe, Malawi
| | - Jennipher Phiri
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
| | - Jeanette C Reece
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia. .,The University of Melbourne Centre for Cancer Research, The University of Melbourne, Parkville, Victoria, Australia.
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Vyas S, Luwanda LB, Guinness L, Kajoka D, Njau P, Renju J, Hassan F, Wringe A. Cost variations in prevention of mother-to-child HIV transmission services integrated within maternal and child health services in rural Tanzania. Glob Public Health 2020; 16:305-318. [PMID: 32726197 DOI: 10.1080/17441692.2020.1798486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We estimated the costs of Option B+ for HIV-infected pregnant women in 12 facilities in Morogoro Region, Tanzania, from a provider perspective. Costs of prevention of mother-to-child (PMTCT) HIV services were measured over 12 months to September 2017 to estimate the average costs per HIV testing episode, per HIV-positive case diagnosed, per patient-year on antiretroviral therapy (ART), and per neonatal HIV care. A one-way sensitivity analysis was undertaken to understand how staffing levels and other core resource inputs affected costs. The total number of HIV testing episodes was 25,593 with 279 HIV cases identified yielding a 1.1% positivity rate. The average cost per testing episode was US$5.49 (range US$2.13 to US$13.93), and the average cost per HIV case detected was US$503.29 (range US$230.61 to US$3330.38). The number of pregnant women initiated on ART was 278. The mean cost per patient-year on ART was US$159.89 (range US$100.91 to US$812.23). The average cost of neonatal HIV care was US$90.09 (range US$41.53 to US$180.26). PMTCT service costs varied widely across facilities due to variations in resource use, number of women testing, and HIV prevalence. The study provides further evidence against generalising cost estimates, and that budgeting and planning requires context specific cost information.
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Affiliation(s)
- Seema Vyas
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Costs and Cost Drivers of Providing Option B+ Services to Mother-Baby Pairs for PMTCT of HIV in Health Centre IV Facilities in Jinja District, Uganda. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2875864. [PMID: 32550228 PMCID: PMC7256705 DOI: 10.1155/2020/2875864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 11/18/2019] [Accepted: 05/04/2020] [Indexed: 11/17/2022]
Abstract
Background In 2013, the World Health Organization (WHO) revised the 2012 guidelines on use of antiretroviral drugs (ARVs) for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). The new guidelines recommended lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and breastfeeding women irrespective of CD4 count or clinical stage (also referred to as Option B+). Uganda started implementing Option B+ in 2012 basing on the 2012 WHO guidelines. Despite the impressive benefits of the Option B+ strategy, implementation challenges, including cost burden and mother-baby pairs lost to follow-up, threatened its overall effectiveness. The researchers were unable to identify any studies conducted to assess costs and cost drivers associated with provision of Option B+ services to mother-baby pairs in HIV care in Uganda. Therefore, this study determined costs and cost drivers of providing Option B+ services to mother-baby pairs over a two-year period (2014–2015) in selected health facilities in Jinja district, Uganda. Methods The estimated costs of providing Option B+ to mother-baby pairs derived from the provider perspective were evaluated at four health centres (HC) in Jinja district. A retrospective, ingredient-based costing approach was used to collect data for 2014 as base year using a standardized cost data capture tool. All costs were valued in United States dollars (USD) using the 2014 midyear exchange rate. Costs incurred in the second year (2015) were obtained by inflating the 2014 costs by the ratio of 2015 and 2014 USA Gross Domestic Product (GDP) implicit price deflator. Results The average total cost of Option B+ services per HC was 66,512.7 (range: 32,168.2–102,831.1) USD over the 2-year period. The average unit cost of Option B+ services per mother-baby pair was USD 441.9 (range: 422.5–502.6). ART for mothers was the biggest driver of total mean costs (percent contribution: 62.6%; range: 56.0%–65.5%) followed by facility personnel (percent contribution: 8.2%; range: 7.7%–11.6%), and facility-level monitoring and quality improvement (percent contribution: 6.0%; range: 3.2%–12.3%). Conclusions and Recommendations. ART for mothers was the major cost driver. Efforts to lower the cost of ART for PMTCT would make delivery of Option B+ affordable and sustainable.
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Ewenighi-Amankwah CO, Onyenekwe CC, Udemba O, Muogbo P, Rong L. A Mother-to-Child Transmission Study in Nigeria: The Impact of Maternal HIV Infection and HAART on Plasma Immunoglobulins, Cytokine Profiles and Infant Outcome. Virol Sin 2020; 35:468-477. [PMID: 32157604 DOI: 10.1007/s12250-020-00202-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/24/2019] [Indexed: 12/18/2022] Open
Abstract
Prevention of mother-to-child transmission (PMTCT) of HIV with highly active antiretroviral therapy (HARRT) allows the HIV+ pregnant mothers to have vaginal delivery and breastfeed. Here we investigated the maternal plasma immunoglobulin, cytokine secretion and the outcome of the exposed infants among the HIV+ HAART treated pregnant women in Nigeria. In this study, different plasma immunoglobulins and cytokines were measured in the HIV+ HAART treated pregnant mothers. Pooled culture supernatants of B and T lymphocytes showed lower levels of IFN-γ, IL-10 and IL-4. There were lower IFN-γ and IL-10 secretions at 1st trimester; however, IL-10 continued to be lower throughout 2nd and 3rd trimesters. TNF-α secretion significantly decreased as pregnancy progressed to term. There were high plasma IgG and low IgM in the HIV+ HAART treated pregnant women. Plasma IgG was high during 1st and 3rd trimesters. After one year of follow up, all the exposed children were seronegative for HIV-1 and HIV-2. Vaginal delivery and breastfeeding among HIV+ HAART treated mothers have shown to be safe. The use of HAART by the infected mothers and the use of septrin and niverapin by the exposed infants prevented mother to-child transmission of HIV.
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Affiliation(s)
- Chinwe O Ewenighi-Amankwah
- Department of Medical Laboratory Science, Ebonyi State University, Abakaliki, 480214, Nigeria. .,Department of Microbiology and Immunology, College of Medicine, University of Illinois at Chicago, Chicago, IL, 60612, USA.
| | - Charles Chinedum Onyenekwe
- Department of Medical Laboratory Science, Faculty of Health Science and Technology, Nnamdi Azikiwe University, Awka, 5025, Nigeria
| | - Ogochukwu Udemba
- Laboratory Unit, Mother of Christ Specialist Hospital, Ogui, Enugu, 400252, Nigeria
| | - Patience Muogbo
- Monitoring and Evaluation Unit, ART Department, Mother of Christ Specialist Hospital, Ogui, Enugu, 400252, Nigeria
| | - Lijun Rong
- Department of Microbiology and Immunology, College of Medicine, University of Illinois at Chicago, Chicago, IL, 60612, USA.
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Demissie DB, Bulto GA, Mekuria WT, Dufera FN, Gamshe EN. <p>Evaluation of Antiretroviral Therapy Initiated Among Pregnant Women Under Option B+ by Viral Load and CD4 Count Outcomes in Selected Hospitals of West Shewa Zone, Oromia Region, Ethiopia</p>. HIV AIDS (Auckl) 2020; 12:127-134. [PMID: 32256122 PMCID: PMC7090176 DOI: 10.2147/hiv.s242320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/10/2020] [Indexed: 11/23/2022] Open
Abstract
Background Antiretroviral therapy (ART) is effective for the elimination of mother-to-child transmission (eMTCT) of human immunodeficiency virus (HIV) infection, reducing infant mortality and ensuring maternal virologic suppression, while pregnant women require test and treat under Option B+ programs. Therefore, the study aimed to assess the evaluation of antiretroviral therapy initiated among pregnant women under Option B+ by viral load and CD4 count outcomes in selected hospitals of West Shewa Zone, Oromia Region, Ethiopia. Methods Hospital-based cross-sectional study design was employed to conduct the study at randomly selected hospitals providing Option B+ services with routine viral load assessment by Oromia Regional Laboratory (ORL) from January 2016 to January 2017. Bivariate and multivariable logistic regression analyses were conducted to determine factors affecting the time to ART initiation following an HIV test and logistic regression was used to determine the correlation between time and treatment outcomes. Results The viral load suppression (VL <1000 copies/mL) was achieved in 31% and 58.7% of patients who were on ART treatment for ≤37 months and longer than 38 months, respectively. It was identified that the mean viral load and CD4 count were 197.27 and 629.17, respectively, while 85.3% of the clients had their CD4 count increased from the baseline data. The study revealed that level of ART adherence, completion of full doses, compliance on appointments, duration of the ART uptake and baseline CD4 count were independent predictors of viral load suppression for women started on option B+ and continued on lifelong ART. And this study also revealed that gestational age at ART start, maternal age in years and adherence on medication were independently associated with CD4 response among HIV pregnant women initiated for lifelong ART. Conclusion The study results demonstrated that for 89.7% of study respondents, viral load was suppressed of which 80.3% were undetectable (VL= 0 copies/ml3 and 85.3% had increased CD4 count). This study determined the factors associated with viral load suppression and CD4 count improvement. Therefore, these factors should be emphatically considered during Option B+ program development and training to ensure CD4 count improvement and viral load suppression achievements.
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Affiliation(s)
- Dereje Bayissa Demissie
- Department of Neonatal Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
- Correspondence: Dereje Bayissa Demissie Email
| | - Gizachew Abdissa Bulto
- Department of Midwifery, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Wagi Tosisa Mekuria
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Fikru Negassa Dufera
- Department of Public Health, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopa
| | - Eriste Nigussa Gamshe
- Department of Neonatal Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Mayaphi SH, Martin DJ, Quinn TC, Stoltz AC. Vertical transmission of HIV among pregnant women who initially had false-negative rapid HIV tests in four South African antenatal clinics. PLoS One 2019; 14:e0226391. [PMID: 31860677 PMCID: PMC6924658 DOI: 10.1371/journal.pone.0226391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/25/2019] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION There is a risk of mother-to-child transmission of HIV (MTCT) during pregnancy and breastfeeding. The aim of this study was to assess vertical transmission of HIV among pregnant women who initially had false-negative rapid HIV tests in South African antenatal care (ANC) clinics. METHODS Pregnant participants were enrolled in a diagnostic study that used nucleic acid amplification testing (NAAT) to screen for early HIV infection among individuals who tested negative on rapid HIV tests used at the point-of-care (POC) facilities. Participants were enrolled from four ANC clinics in the Tshwane district of South Africa. All NAAT-positive participants were recalled to the clinics for further management. Vertical transmission was assessed among exposed infants whose HIV polymerase chain reaction (PCR) results were available. RESULTS This study enrolled 8208 pregnant participants who tested negative on rapid HIV tests between 2013 and 2016. Their median age was 26 years (interquartile range [IQR]: 23-30). NAAT detected HIV infections in 0.6% (n = 49; 95% confidence interval {CI}: 0.5-0.8) of all study participants. The distribution of these infections among the four clinics ranged from 0.3%- 1.1%, but this was not statistically significant (p = 0.07). Forty-seven participants (95.9%) were successfully recalled and referred for antiretroviral treatment initiation as part of prevention of MTCT (PMTCT). Most women with newly diagnosed HIV infection presented for the first ANC visit in the second (61.9%, n = 26) and third (31.0%, n = 13) trimesters. HIV PCR results were available for thirty-two infants, three of whom tested positive (9.4%; 95% CI: 1.98-25.02). CONCLUSIONS This study showed that supplemental HIV testing for pregnant women led to earlier linkage to the PMTCT programme. Inaccurate diagnosis of HIV infection at ANC clinics is likely to undermine the efforts of eliminating MTCT particularly in HIV-endemic settings.
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Affiliation(s)
- Simnikiwe H. Mayaphi
- Department of Medical Virology, University of Pretoria, City of Tshwane, South Africa
- National Health Laboratory Service–Tshwane Academic Division (NHLS–TAD), City of Tshwane, South Africa
| | - Desmond J. Martin
- Department of Medical Virology, University of Pretoria, City of Tshwane, South Africa
- Toga Laboratories, Johannesburg, South Africa
| | - Thomas C. Quinn
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Anton C. Stoltz
- Division of Infectious Diseases, Department of Internal Medicine, University of Pretoria, City of Tshwane, South Africa
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Wang X, Guo G, Zheng J, Lu L. Cost-effectiveness of option B+ in prevention of mother-to-child transmission of HIV in Yunnan Province, China. BMC Infect Dis 2019; 19:517. [PMID: 31185927 PMCID: PMC6560771 DOI: 10.1186/s12879-019-3976-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 04/11/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Although Option B+ may be more costly than Options B, it may provide additional health benefits that are currently unclear in Yunnan province. We created deterministic models to estimate the cost-effectiveness of Option B+. METHODS Data were used in two deterministic models simulating a cohort of 2000 HIV+ pregnant women. A decision tree model simulated the number of averted infants infections and QALY acquired for infants in the PMTCT period for Options B and B+. The minimum cost was calculated. A Markov decision model simulated the number of maternal life year gained and serodiscordant partner infections averted in the ten years after PMTCT for Option B or B+. ICER per life year gained was calculated. Deterministic sensitivity analyses were conducted. RESULTS If fully implemented, Option B and Option B+ averted 1016.85 infections and acquired 588,01.02 QALYs.The cost of Option B was US$1,229,338.47, the cost of Option B+ was 1,176,128.63. However, when Options B and B+ were compared over ten years, Option B+ not only improved mothers'ten-year survival from 69.7 to 89.2%, saving more than 3890 life-years, but also averted 3068 HIV infections between serodiscordant partners. Option B+ yielded a favourable ICER of $32.99per QALY acquired in infants and $5149per life year gained in mothers. A 1% MTCT rate, a 90% coverage rate and a 20-year horizon could decrease the ICER per QALY acquired in children and LY gained in mothers. CONCLUSIONS Option B+ is a cost-effective treatment for comprehensive HIV prevention for infants and serodiscordant partners and life-long treatment for mothers in Yunnan province, China. Option B+ could be implemented in Yunnan province, especially as the goals of elimination mother-to-child transmission of HIV and "90-90-90" achieved, Option B+ would be more attractive.
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Affiliation(s)
- Xiaowen Wang
- Yunnan Center for Disease Control and Prevention, No 158, Dongsi Street, Xishan District, Kunming, Yunnan Province China
- Kunming Medical University, No. 1168, west Chunrong Street, Chenggong district, Kunming, Yunnan Province China
| | - Guangping Guo
- Yunnan Maternal and Child Health Care Hospital, No. 200, Gulou Street, Wuhua District, Kunming, Yunnan Province China
| | - Jiarui Zheng
- Yunnan Maternal and Child Health Care Hospital, No. 200, Gulou Street, Wuhua District, Kunming, Yunnan Province China
| | - Lin Lu
- Kunming Medical University, No. 1168, west Chunrong Street, Chenggong district, Kunming, Yunnan Province China
- Health Commission of Yunnan Province, No. 309, Guomao Street, Kunming, Yunnan Province China
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Kawakyu N, Nduati R, Munguambe K, Coutinho J, Mburu N, DeCastro G, Inguane C, Zunt A, Abburi N, Sherr K, Gimbel S. Development and Implementation of a Mobile Phone-Based Prevention of Mother-To-Child Transmission of HIV Cascade Analysis Tool: Usability and Feasibility Testing in Kenya and Mozambique. JMIR Mhealth Uhealth 2019; 7:e13963. [PMID: 31094351 PMCID: PMC6535976 DOI: 10.2196/13963] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/20/2019] [Accepted: 04/23/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Prevention of mother-to-child HIV transmission (PMTCT) care cascade failures drive pediatric HIV infections in sub-Saharan Africa. As nurses' clinical and management role in PMTCT expand, decision-support tools for nurses are needed to facilitate identification of cascade inefficiencies and solutions. The mobile phone-based PMTCT cascade analysis tool (mPCAT) provides health facility staff a quick summary of the number of patients and percentage drop-off at each step of the PMCTC care cascade, as well as how many women-infant pairs would be retained if a step was optimized. OBJECTIVE The objective of this study was to understand and improve the mPCAT's core usability factors and assess the health workers' experience with using the mPCAT. METHODS Overall, 2 rounds of usability testing were conducted with health workers from 4 clinics and leading experts in maternal and child health in Kenya and Mozambique using videotaped think aloud assessment techniques. Semistructured group interviews gauged the understanding of mPCAT's core usability factors, based on the Nielsen Usability Framework, followed by development of cognitive demand tables describing the needed mPCAT updates. Post adaptation, feasibility was assessed in 3 high volume clinics over 12 weeks. Participants completed a 5-point Likert questionnaire designed to measure ease of use, convenience of integration into work, and future intention to use the mPCAT. Focus group discussions with nurse participants at each facility and in-depth interviews with nurse managers were also conducted to assess the acceptability, use, and recommendations for adaptations of the mPCAT. RESULTS Usability testing with software engineers enabled real-time feedback to build a tool following empathic design principles. The revised mPCAT had improved navigation and simplified data entry interface, with only 1 data entry field per page. Improvements to the results page included a data visualization feature and the ability to share results through WhatsApp. Coding was simplified to enable future revisions by nontechnical staff-critical for context-specific adaptations for scale-up. Health care workers and facility managers found the tool easy to use (mean=4.3), used the tool very often (mean=4.1), and definitely intended to continue to use the tool (mean=4.8). Ease of use was the most common theme identified, with emphasis on how the tool readily informed system improvement decision making. CONCLUSIONS The mPCAT was well accepted by frontline health workers and facility managers. The collaborative process between software developer and user led to the development of a more user-friendly, context-specific tool that could be easily integrated into routine clinical practice and workflow. The mPCAT gave frontline health workers and facility managers an immediate, direct, and tangible way to use their clinical documentation and routinely reported data for decision making for their own clinical practice and facility-level improvements.
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Affiliation(s)
- Nami Kawakyu
- Center for Global Health Nursing, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Ruth Nduati
- Network of AIDS Researchers in East and Southern Africa, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Khátia Munguambe
- University of Eduardo Mondlane, Maputo, Mozambique
- Manhiça Health Research Centre, Manhiça, Mozambique
| | - Joana Coutinho
- Health Alliance International, Beira / Chimoio, Mozambique
| | - Nancy Mburu
- Network of AIDS Researchers in East and Southern Africa, Nairobi, Kenya
| | | | - Celso Inguane
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Andrew Zunt
- Paul G Allen School of Computer Science and Engineering, University of Washington, Seattle, WA, United States
| | - Neil Abburi
- Paul G Allen School of Computer Science and Engineering, University of Washington, Seattle, WA, United States
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States
- Health Alliance International, Seattle, WA, United States
| | - Sarah Gimbel
- Center for Global Health Nursing, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Health Alliance International, Seattle, WA, United States
- Department of Family and Child Nursing, University of Washington, Seattle, WA, United States
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Sarkar S, Corso P, Ebrahim-Zadeh S, Kim P, Charania S, Wall K. Cost-effectiveness of HIV Prevention Interventions in Sub-Saharan Africa: A Systematic Review. EClinicalMedicine 2019; 10:10-31. [PMID: 31193863 PMCID: PMC6543190 DOI: 10.1016/j.eclinm.2019.04.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa carries the highest HIV burden globally. It is important to understand how interventions cost-effectively fit within guidelines and implementation plans, especially in low- and middle-income settings. We reviewed the evidence from economic evaluations of HIV prevention interventions in sub-Saharan Africa to help inform the allocation of limited resources. METHODS We searched PubMed, Web of Science, Econ-Lit, Embase, and African Index Medicus. We included studies published between January 2009 and December 2018 reporting cost-effectiveness estimates of HIV prevention interventions. We extracted health outcomes and cost-effectiveness ratios (CERs) and evaluated study quality using the CHEERS checklist. FINDINGS 60 studies met the full inclusion criteria. Prevention of mother-to-child transmission interventions had the lowest median CERs ($1144/HIV infection averted and $191/DALY averted), while pre-exposure prophylaxis interventions had the highest ($13,267/HIA and $799/DALY averted). Structural interventions (partner notification, cash transfer programs) have similar CERs ($3576/HIA and $392/DALY averted) to male circumcision ($2965/HIA) and were more favourable to treatment-as-prevention interventions ($7903/HIA and $890/DALY averted). Most interventions showed increased cost-effectiveness when prioritizing specific target groups based on age and risk. INTERPRETATION The presented cost-effectiveness information can aid policy makers and other stakeholders as they develop guidelines and programming for HIV prevention plans in resource-constrained settings.
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Affiliation(s)
- Supriya Sarkar
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Phaedra Corso
- Department of Health Policy and Management, Kennesaw State University, Kennesaw, GA, USA
| | | | - Patricia Kim
- Department of Economics, Emory University, Atlanta, GA, USA
| | - Sana Charania
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kristin Wall
- Department of Epidemiology, Emory University, Atlanta, GA, USA
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Toward Improving Accessibility of Point-of-Care Diagnostic Services for Maternal and Child Health in Low- and Middle-Income Countries. POINT OF CARE 2019; 18:17-25. [PMID: 30886544 PMCID: PMC6407818 DOI: 10.1097/poc.0000000000000180] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Point-of-care (POC) testing can improve health care provision in settings with limited access to health care services. Access to POC diagnostic services has shown potential to alleviate some diagnostic challenges and delays associated with laboratory-based methods in low- and middle-income countries. Improving accessibility to POC testing (POCT) services during antenatal and perinatal care is among the global health priorities to improve maternal and child health. This review provides insights on the availability of POC testing designed for diagnosing HIV, syphilis, and malaria in pregnancy to improve maternal and child health. In addition, factors such as accessibility of POC testing, training of health work force, and the efficiency of POC testing services delivery in low- and middle-income countries are discussed. A framework to help increase access to POC diagnostic services and improve maternal and child health outcomes in low- and middle-income countries is proposed.
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Cunnama L, Abrams EJ, Myer L, Gachuhi A, Dlamini N, Hlophe T, Kikuvi J, Langwenya N, Mthethwa S, Mudonhi D, Nhlabatsi B, Nuwagaba-Biribonwoha H, Okello V, Sahabo R, Zerbe A, Sinanovic E. Cost and cost-effectiveness of transitioning to universal initiation of lifelong antiretroviral therapy for all HIV-positive pregnant and breastfeeding women in Swaziland. Trop Med Int Health 2018; 23:950-959. [PMID: 29956426 DOI: 10.1111/tmi.13121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess the costs and cost-effectiveness of transitioning from antiretroviral therapy (ART) initiation based on CD4 cell count and WHO clinical staging ('Option A') to universal ART ('Option B+') for all HIV-infected pregnant and breastfeeding women in Swaziland. METHODS We measured the total costs of prevention of mother-to-child HIV transmission (PMTCT) service delivery at public sector facilities with empirical cost data collected at three points in time: once under Option A and again twice after transition to the Option B+ approach. The cost per woman treated per month includes recurrent costs (personnel, overheads, medication and diagnostic tests) and capital costs (buildings, furniture, start-up costs and training). Cost-effectiveness was estimated from the health services perspective as the cost per woman retained in care through 6 months postpartum. This analysis is nested within a larger stepped-wedge evaluation, which demonstrated a 26% increase in maternal retention after the transition to Option B+. RESULTS Across the five sites, the total cost for PMTCT during the study period (from August 2013 to October 2015, in 2015 US$) was $868,426 for Option B+ and $680 508 for Option A. The cost per woman treated per month was $183 for a woman on ART under Option B+, and $127 and $118 for a woman on ART and zidovudine (AZT), respectively, under Option A. The weighted average cost per woman treated on Option B+ was $826 compared to $525 under Option A. The main cost drivers were the start-up costs, additional training provided and staff time spent on PMTCT tasks for Option B+. The incremental cost-effectiveness ratio was estimated at $912 for every additional mother retained in care through six months postpartum. CONCLUSIONS The cost and cost-effectiveness outcomes from this study indicate that there is a robust economic case for pursuing the Option B+ approach in Swaziland and similar settings such as South Africa. Furthermore, these costs can be used to aid decision making and budgeting, for similar settings transitioning to test and treat strategy.
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Affiliation(s)
- L Cunnama
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - E J Abrams
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA.,College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - L Myer
- Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa
| | - A Gachuhi
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA
| | - N Dlamini
- ICAP at Columbia University, Mbabane, Swaziland
| | - T Hlophe
- Monitoring & Evaluation, Deputy Prime Minister's Office, Mbabane, Swaziland
| | - J Kikuvi
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - N Langwenya
- Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa
| | - S Mthethwa
- Swaziland Ministry of Health, Mbabane, Swaziland
| | - D Mudonhi
- ICAP at Columbia University, Mbabane, Swaziland
| | - B Nhlabatsi
- Swaziland Ministry of Health, Mbabane, Swaziland
| | - H Nuwagaba-Biribonwoha
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA.,ICAP at Columbia University, Mbabane, Swaziland
| | - V Okello
- Swaziland Ministry of Health, Mbabane, Swaziland
| | - R Sahabo
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA.,ICAP at Columbia University, Mbabane, Swaziland
| | - A Zerbe
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA
| | - E Sinanovic
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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Vrazo AC, Sullivan D, Ryan Phelps B. Eliminating Mother-to-Child Transmission of HIV by 2030: 5 Strategies to Ensure Continued Progress. GLOBAL HEALTH, SCIENCE AND PRACTICE 2018; 6:249-256. [PMID: 29959270 PMCID: PMC6024627 DOI: 10.9745/ghsp-d-17-00097] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 04/04/2018] [Indexed: 01/26/2023]
Abstract
To keep up momentum in preventing mother-to-child transmission we propose: (1) advocating for greater political and financial commitment; (2) targeting high-risk populations such as adolescent girls and young women; (3) implementing novel service delivery models such as community treatment groups; (4) performing regular viral load monitoring during pregnancy and postpartum to ensure suppression before delivery and during breastfeeding; and (5) harnessing technology in monitoring and evaluation and HIV diagnostics.
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Affiliation(s)
- Alexandra C Vrazo
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA.
| | - David Sullivan
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Benjamin Ryan Phelps
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
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Chersich MF, Newbatt E, Ng’oma K, de Zoysa I. UNICEF's contribution to the adoption and implementation of option B+ for preventing mother-to-child transmission of HIV: a policy analysis. Global Health 2018; 14:55. [PMID: 29859098 PMCID: PMC5984744 DOI: 10.1186/s12992-018-0369-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/06/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Between 2011 and 2013, global and national guidelines for preventing mother-to-child transmission (PMTCT) of HIV shifted to recommend Option B+, the provision of lifelong antiretroviral treatment for all HIV-infected pregnant women. METHODS We aimed to analyse how Option B+ reached the policy agenda, and unpack the processes, actors and politics that explain its adoption, with a focus on examining UNICEF's contribution to these events. Analysis drew on published articles and other documentation, 30 key informants interviews with staff at UNICEF, partner organisations and government officials, and country case studies. Cameroon, India, South Africa and Zimbabwe were each visited for 5-8 days. Interview transcripts were analysed using Dedoose software, reviewed several times and then coded thematically. RESULTS A national policy initiative in Malawi in 2011, in which the country adopted Option B+, rather than existing WHO recommended regimens, irrevocably placed the policy on the global agenda. UNICEF and other organisations recognised the policy's potential impact and strategically crafted arguments to support it, framing these around operational considerations, cost-effectiveness and values. As 'policy entrepreneurs', these organisations vigorously promoted the policy through a variety of channels and means, overcoming concerted opposition. WHO, on the basis of scanty evidence, released a series of documents towards the policy's endorsement, paving the way for its widespread adoption. National-level policy transformation was rapid and definitive, distinct from previous incremental policy processes. Many organisations, including UNICEF, facilitated these changes in country, acting individually, or in concert. CONCLUSIONS The adoption of the Option B+ policy marked a departure from established processes for PMTCT policy formulation which had been led by WHO with the support of technical experts, and in which recommendations were developed following shifts in evidence. Rather, changes were spurred by a country-level initiative, and a set of strategically framed arguments that resonated with funders and country-level actors. This bottom-up approach, supported by normative agencies, was transformative. For UNICEF, alignment between the organisation's country focus and the policy's underpinning values, enabled it to work with partners and accelerate widespread policy change.
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Affiliation(s)
- M. F. Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - K. Ng’oma
- United Nations Children’s Fund, Pretoria, South Africa
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Abimpaye M, Kirk CM, Iyer HS, Gupta N, Remera E, Mugwaneza P, Law MR. The impact of "Option B" on HIV transmission from mother to child in Rwanda: An interrupted time series analysis. PLoS One 2018; 13:e0192910. [PMID: 29451925 PMCID: PMC5815596 DOI: 10.1371/journal.pone.0192910] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 01/22/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nearly a quarter of a million children have acquired HIV, prompting the implementation of new protocols-Option B and B+-for treating HIV+ pregnant women. While efficacy has been demonstrated in randomized trials, there is limited real-world evidence on the impact of these changes. Using longitudinal, routinely collected data we assessed the impact of the adoption of WHO Option B in Rwanda on mother to infant transmission. METHODS We used interrupted time series analysis to evaluate the impact of Option B on mother-to-child HIV transmission in Rwanda. Our primary outcome was the proportion of HIV tests in infants with positive results at six weeks of age. We included data for 20 months before and 22 months after the 2010 policy change. RESULTS Of the 15,830 HIV tests conducted during our study period, 392 tested positive. We found a significant decrease in both the level (-2.08 positive tests per 100 tests conducted, 95% CI: -2.71 to -1.45, p < 0.001) and trend (-0.11 positive tests per 100 tests conducted per month, 95% CI: -0.16 to -0.07, p < 0.001) of test positivity. This represents an estimated 297 fewer children born without HIV in the post-policy period or a 46% reduction in HIV transmission from mother to child. CONCLUSIONS The adoption of Option B in Rwanda contributed to an immediate decrease in the rate of HIV transmission from mother to child. This suggests other countries may benefit from adopting these WHO guidelines.
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Affiliation(s)
| | | | - Hari S. Iyer
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
- Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Neil Gupta
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
- Brigham and Women’s Hospital, Boston, MA, United States of America
| | | | | | - Michael R. Law
- The University of British Columbia, Vancouver, British Columbia, Canada
- University of Rwanda, Kigali, Rwanda
- Harvard Medical School, Boston, MA, United States of America
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Abstract
HIV testing of African immigrants in Belgium showed that HIV existed among Africans by 1983. However, the epidemic was recognized much later in most parts of sub-Saharan Africa (SSA) due to stigma and perceived fear of possible negative consequences to the countries' economies. This delay had devastating mortality, morbidity, and social consequences. In countries where earlier recognition occurred, political leadership was vital in mounting a response. The response involved establishment of AIDS control programs and research on the HIV epidemiology and candidate preventive interventions. Over time, the number of effective interventions has grown; the game changer being triple antiretroviral therapy (ART). ART has led to a rapid decline in HIV-related morbidity and mortality in addition to prevention of onward HIV transmission. Other effective interventions include safe male circumcision, pre-exposure prophylaxis, and post-exposure prophylaxis. However, since none of these is sufficient by itself, delivering a combination package of these interventions is important for ending the HIV epidemic as a public health threat.
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Affiliation(s)
- Joseph Kagaayi
- Rakai Health Sciences Program, Uganda Virus Research Institute, Nakiwogo Road, PO BOX 49, Entebbe, Uganda
| | - David Serwadda
- Rakai Health Sciences Program, Uganda Virus Research Institute, Nakiwogo Road, PO BOX 49, Entebbe, Uganda. .,Makerere University School of Public Health, Old Mulago Hill Road, New Mulago Hospital Complex, P.o.Box 7072, Kampala, Uganda.
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Ngambi PG, Kalungia AC, Law MR, Kalemeera F, Truter II, Godman B, Munkombwe D. Evidence on the cost-effectiveness of lifelong antiretroviral therapy for prevention of mother-to-child transmission of HIV: implications for resource-limited countries in sub-Saharan Africa. Expert Rev Pharmacoecon Outcomes Res 2017; 17:459-467. [PMID: 28770641 DOI: 10.1080/14737167.2017.1364161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The 2016 World Health Organization (WHO) consolidated guideline recommends lifelong antiretroviral therapy (ART) for all HIV-infected pregnant and breastfeeding women for preventing mother-to-child HIV transmission (PMTCT). Ambiguity remains about the cost-effectiveness of this strategy in resource-limited developing countries. Areas covered: We reviewed model-based studies on the cost-effectiveness of lifelong ART (formerly Option B+) relative to previous WHO guidelines for PMTCT. Our search using PubMed, Medline and Google Scholar for articles on Option B+ resulted in the final inclusion of seven studies published between 2012 and 2016. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used to assess the quality of reporting. Outcomes of interest, which included infant infections averted, maternal quality and length of life, and the Incremental Cost Effectiveness Ratio (ICER), were used in comparing cost-effectiveness. Expert commentary: Despite most model-based studies favouring lifelong ART (Option B+) in terms of its cost-effectiveness in comparison to Options A and B, inclusiveness of the evidence remains weak for generalization. This is largely because setting specificity for providing lifelong ART to all pregnant and breastfeeding women may differ significantly in each setting. Consequently, future cost-effectiveness studies should be robust, setting-specific, and endeavor to assess the willingness and ability to pay of each setting.
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Affiliation(s)
- Peslie G Ngambi
- a Manchester Centre for Health Economics , University of Manchester , Manchester , UK
| | | | - Michael R Law
- c Centre for Health Services and Policy Research , The University of British Columbia , Vancouver , Canada
| | - Francis Kalemeera
- d Department of Pharmacology & Therapeutics , University of Namibia , Windhoek , Namibia
| | - IIse Truter
- e Drug Utilization Research Unit (DURU), Department of Pharmacy , Nelson Mandela Metropolitan University , Port Elizabeth , South Africa
| | - Brian Godman
- f Division of Clinical Pharmacology , Karolinska Institute , Stockholm , Sweden.,g Strathclyde Institute of Pharmacy and Biomedical Sciences , University of Strathclyde , Glasgow , UK.,h Health Economics Centre , Liverpool University Management School , Liverpool , UK
| | - Derick Munkombwe
- b Department of Pharmacy , University of Zambia , Lusaka , Zambia
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Modeling the Cost-Effectiveness of Home-Based HIV Testing and Education (HOPE) for Pregnant Women and Their Male Partners in Nyanza Province, Kenya. J Acquir Immune Defic Syndr 2017; 72 Suppl 2:S174-80. [PMID: 27355506 PMCID: PMC5113236 DOI: 10.1097/qai.0000000000001057] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Supplemental Digital Content is Available in the Text. Introduction: Women in sub-Saharan Africa face a 2-fold higher risk of HIV acquisition during pregnancy and postpartum and the majority do not know the HIV status of their male partner. Home-based couple HIV testing for pregnant women can reduce HIV transmission to women and infants while increasing antiretroviral therapy (ART) coverage in men. However, the cost-effectiveness of this program has not been evaluated. Methods: We modeled the health and economic impact of implementing a home-based partner education and HIV testing (HOPE) intervention for pregnant women and their male partners in a region of Western Kenya (formally Nyanza Province). We used data from the HOPE randomized clinical trial conducted in Kisumu, Kenya, to parameterize a mathematical model of HIV transmission. We conducted an in-country microcosting of the HOPE intervention (payer perspective) to estimate program costs as well as a lower cost scenario of task-shifting to community health workers. Results: The incremental cost of adding the HOPE intervention to standard antenatal care was $31–37 and $14–16 USD per couple tested with program and task-shifting costs, respectively. At 60% coverage of male partners, HOPE was projected to avert 6987 HIV infections and 2603 deaths in Nyanza province over 10 years with an incremental cost-effectiveness ratio (ICER) of $886 and $615 per disability-adjusted life year averted for the program and task-shifting scenario, respectively. ICERs were robust to changes in intervention coverage, effectiveness, and ART initiation and dropout rates. Conclusions: The HOPE intervention can moderately decrease HIV-associated morbidity and mortality by increasing ART coverage in male partners of pregnant women. ICERs fall below Kenya's per capita gross domestic product ($1358) and are therefore considered cost-effective. Task-shifting to community health workers can increase intervention affordability and feasibility.
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Helova A, Akama E, Bukusi EA, Musoke P, Nalwa WZ, Odeny TA, Onono M, Spangler SA, Turan JM, Wanga I, Abuogi LL. Health facility challenges to the provision of Option B+ in western Kenya: a qualitative study. Health Policy Plan 2017; 32:283-291. [PMID: 28207061 PMCID: PMC5886182 DOI: 10.1093/heapol/czw122] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2016] [Indexed: 01/03/2023] Open
Abstract
Current WHO guidelines recommend lifelong antiretroviral therapy (ART) for all HIV-positive individuals, including pregnant and breastfeeding women (Option B+) in settings with generalized HIV epidemics. While Option B+ is scaled-up in Kenya, insufficient adherence and retention to care could undermine the expected positive impact of Option B+. To explore challenges to the provision of Option B+ at the health facility level, we conducted forty individual gender-matched in-depth interviews with HIV-positive pregnant/postpartum women and their male partners, and four focus groups with thirty health care providers at four health facilities in western Kenya between September-November 2014. Transcripts were coded with the Dedoose software using a coding framework based on the literature, topics from interview guides, and emerging themes from transcripts. Excerpts from broad codes were then fine-coded using an inductive approach. Three major themes emerged: 1) Option B+ specific challenges (same-day initiation into treatment, health care providers unconvinced of the benefits of Option B+, insufficient training); 2) facility resource constraints (staff and drug shortages, long queues, space limitations); and 3) lack of client-friendly services (scolding of patients, inconvenient operating hours, lack of integration of services, administrative requirements). This study highlights important challenges at the health facility level related to Option B+ rollout in western Kenya. Addressing these specific challenges may increase linkage, retention and adherence to life-long ART treatment for pregnant HIV-positive women in Kenya, contribute towards elimination of mother-to-child HIV transmission, and improve maternal and child outcomes.
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Affiliation(s)
- Anna Helova
- Department of Health Care Organization and Policy School of Public Health, University of Alabama at Birmingham, Birmingham, Birmingham, Alabama, US
| | - Eliud Akama
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Pamela Musoke
- Department of Health Care Organization and Policy School of Public Health, University of Alabama at Birmingham, Birmingham, Birmingham, Alabama, US
| | - Wafula Z Nalwa
- Migori County Referral Hospital, Kenya Ministry of Health, Migori, Kenya
| | - Thomas A Odeny
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, US
| | - Maricianah Onono
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Sydney A Spangler
- Nell Hodgson Woodruff School of Nursing and Department of Global Health, Emory University, Atlanta, Georgia, US
| | - Janet M Turan
- Department of Health Care Organization and Policy School of Public Health, University of Alabama at Birmingham, Birmingham, Birmingham, Alabama, US
| | - Iris Wanga
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lisa L Abuogi
- Department of Pediatrics, University of Colorado Denver, Aurora, Colorado, US
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Outcomes and Cost-Effectiveness of Integrating HIV and Nutrition Service Delivery: Pilots in Malawi and Mozambique. AIDS Behav 2017; 21:703-711. [PMID: 27094787 DOI: 10.1007/s10461-016-1400-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This paper provides the first estimates of impact and cost-effectiveness for integrated HIV and nutrition service delivery in sub-Saharan Africa. HIV and undernutrition are synergistic co-epidemics impacting millions of children throughout the region. To alleviate this co-epidemic, UNICEF supported small-scale pilot programs in Malawi and Mozambique that integrated HIV and nutrition service delivery. We use trends from integration sites and comparison sites to estimate the number of lives saved, infections averted and/or undernutrition cases cured due to programmatic activities, and to estimate cost-effectiveness. Results suggest that Malawi's program had a cost-effectiveness of $11-29/DALY, while Mozambique's was $16-59/DALY. Some components were more effective than others ($1-4/DALY for Malawi's Male motivators vs. $179/DALY for Mozambique's One stop shops). These results suggest that integrating HIV and nutrition programming leads to a positive impact on health outcomes and should motivate additional work to evaluate impact and determine cost-effectiveness using an appropriate research design.
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Zegeye EA, Mbonigaba J, Kaye SB, Wilkinson T. Economic Evaluation in Ethiopian Healthcare Sector Decision Making: Perception, Practice and Barriers. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:33-43. [PMID: 27637919 DOI: 10.1007/s40258-016-0280-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Globally, economic evaluation (EE) is increasingly being considered as a critical tool for allocating scarce healthcare resources. However, such considerations are less documented in low-income countries, such as in Ethiopia. In particular, to date there has been no assessment conducted to evaluate the perception and practice of and barriers to health EE. OBJECTIVE This paper assesses the use and perceptions of EE in healthcare decision-making processes in Ethiopia. METHODS In-depth interview sessions with decision makers/healthcare managers and program coordinators across six regional health bureaus were conducted. A qualitative analysis approach was conducted on three thematic areas. RESULTS A total of 57 decision makers/healthcare managers were interviewed from all tiers of the health sector in Ethiopia, ranging from the Federal Ministry of Health down to the lower levels of the health facility pyramid. At the high-level healthcare decision-making tier, only 56 % of those interviewed showed a good understanding of EE when explaining in terms of cost and consequences of alternative courses of action and value for money. From the specific program perspective, 50 % of the prevention of mother-to-child transmission of HIV/AIDS program coordinators indicated the relevance of EE to program planning and decision making. These respondents reported a limited application of costing studies on the HIV/AIDS prevention and control program, which were most commonly used during annual planning and budgeting. CONCLUSION The study uncovered three important barriers to growth of EE in Ethiopia: a lack of awareness, a lack of expertise and skill, and the traditional decision-making culture.
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Affiliation(s)
- Elias Asfaw Zegeye
- Economics Department, School of Accounting, Economics and Finance, University of KwaZulu-Natal, Durban, South Africa.
| | - Josue Mbonigaba
- Economics Department, School of Accounting, Economics and Finance, University of KwaZulu-Natal, Durban, South Africa
| | - Sylvia Blanche Kaye
- School of Public Management and Economics, Durban University of Technology, Durban, South Africa
| | - Thomas Wilkinson
- PRICELESS SA, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Hampanda KM, Abuogi LL, Ahmed Y. HIV-Positive Women Taking Lifelong Antiretroviral Therapy Report Better Adherence Than Women Taking Short-Course Prophylaxis During and After Pregnancy Under PMTCT Program Option A in Lusaka, Zambia. Int J MCH AIDS 2017; 6:27-35. [PMID: 28798891 PMCID: PMC5547223 DOI: 10.21106/ijma.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES HIV-positive women's adherence to antiretrovirals is critical for prevention of mother-to-child transmission. We aimed to establish if mothers taking triple lifelong antiretroviral therapy report higher adherence compared to mothers taking short-course prophylaxis under Option A in Lusaka, Zambia. METHODS In this clinic-based cross-sectional study, we interviewed 320 HIV-positive mothers at a large public health facility in Lusaka in 2014. Participants reported adherence using a visual analog scale. Multiple logistic regression models were used to determine the adjusted odds of adherence by mother's prescribed regimen. RESULTS Women taking lifelong triple antiretroviral therapy report higher adjusted odds of adherence during pregnancy, postpartum, and to giving the infant prophylaxis compared to women to women taking short-course prophylaxis. DISCUSSION Women on lifelong therapy may have better adherence compared to women on short course prophylaxis because they knew their positive status for longer or were symptomatic with HIV-related disease. The lifelong therapy regimen may be easier for women to follow, particularly because they are required to give the infant prophylaxis for a shorter duration of time. CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS Our results indicate that lifelong triple antiretroviral therapy has the potential to promote better drug adherence during and after pregnancy among women living with HIV in sub-Saharan Africa, compared to short-course antiretroviral regimens.
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Affiliation(s)
- Karen M Hampanda
- Department of Community and Behavioral Health, University of Colorado School of Public Health, Aurora, CO 80045, USA
| | - Lisa L Abuogi
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO 80045, USA.,Center for Global Health, University of Colorado School of Medicine, School of Public Health, Aurora, CO 80045, USA
| | - Yusuf Ahmed
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
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Atanga PN, Ndetan HT, Achidi EA, Meriki HD, Hoelscher M, Kroidl A. Retention in care and reasons for discontinuation of lifelong antiretroviral therapy in a cohort of Cameroonian pregnant and breastfeeding HIV-positive women initiating 'Option B+' in the South West Region. Trop Med Int Health 2016; 22:161-170. [PMID: 27865052 DOI: 10.1111/tmi.12816] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess linkage and retention in care along the PMTCT cascade in HIV-positive pregnant and breastfeeding women initiating Option B+ in Cameroon. METHODS We prospectively determined uptake of HIV testing and counselling (HTC), uptake of ART and retention in care after Option B+ initiation between October 2013 and December 2014 in pregnant and breastfeeding women from five sites within the Kumba Health District. Retention in care was assessed over at least 12 months follow-up and estimated by Kaplan-Meier analysis. During follow-up, tracing outcomes and reasons for discontinuing treatment were documented. RESULTS The uptake of HTC of 5813 women with unknown HIV status was 98.5%, 251 (4.4%) were newly diagnosed HIV positive, and ART uptake in women eligible to start Option B+ was 96.8%. We enrolled 268 women initiating lifelong ART in the follow-up. Overall, 65 (24.3%) discontinued treatment, either defined by loss to follow-up (44.6%) or actively stopped treatment (55.8%). Retention in care was 88.0% and 81.1% at 6 and 12 months, respectively. Discontinuation was significantly associated in multivariate analysis with small sites and high staff turnover [aOR 2.5 (95% CI 1.6, 3.9), P < 0.001]. Main reasons for stopping treatment were HIV status denial and stigma (52.8%), religious reasons (25.0%) and lack of transport fare (11.1%). CONCLUSION We observed good uptake of HTC, ART and retention in care, which declined over time. Discontinuation of Option B+ was highest at small sites with a high staff turnover. Improved staffing, adequate task shifting and community interventions to track defaulters including reducing stigma and religious beliefs may improve Option B+ retention.
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Affiliation(s)
- Pascal N Atanga
- Department of Public Health and Hygiene, University of Buea, Buea, Cameroon.,Centre for International Health, University of Munich, Munich, Germany
| | - Harrison T Ndetan
- Research Institute, Parker University, Dallas, TX, USA.,Department of Biostatistics and Epidemiology, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Eric A Achidi
- Faculty of Sciences, University of Buea, Buea, Cameroon
| | - Henry D Meriki
- Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon.,Laboratory Department, Regional Hospital Buea, Buea, Cameroon
| | - Michael Hoelscher
- Centre for International Health, University of Munich, Munich, Germany.,Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany
| | - Arne Kroidl
- Centre for International Health, University of Munich, Munich, Germany.,German Centre for Infection Research, Partner Site Munich, Munich, Germany
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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. J Int AIDS Soc 2016; 19:21212. [PMID: 27978939 PMCID: PMC5159683 DOI: 10.7448/ias.19.1.21212] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 10/07/2016] [Accepted: 11/14/2016] [Indexed: 11/08/2022] Open
Abstract
Introduction HIV 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. Methods We 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. Results When 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. Conclusions Universal 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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Llenas-García J, Wikman-Jorgensen P, Hobbins M, Mussa MA, Ehmer J, Keiser O, Mbofana F, Wandeler G. Retention in care of HIV-infected pregnant and lactating women starting ART under Option B+ in rural Mozambique. Trop Med Int Health 2016; 21:1003-1012. [PMID: 27208807 DOI: 10.1111/tmi.12728] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE In 2013, Mozambique adopted Option B+, universal lifelong antiretroviral therapy (ART) for all pregnant and lactating women, as national strategy for prevention of mother-to-child transmission of HIV. We analysed retention in care of pregnant and lactating women starting Option B+ in rural northern Mozambique. METHODS We compared ART outcomes in pregnant ('B+ pregnant'), lactating ('B+ lactating') and non-pregnant non-lactating women of childbearing age starting ART according to clinical and/or immunological criteria ('own health') between July 2013 and June 2014. Lost to follow-up was defined as no contact >180 days after the last visit. Multivariable competing risk models were adjusted for type of facility (type 1 vs. peripheral type 2 health centre), age, WHO stage and time from HIV diagnosis to ART. RESULTS Over 333 person-years of follow-up (243 'B+ pregnant', 65'B+ lactating' and 317 'own health' women), 3.7% of women died and 48.5% were lost to follow-up. 'B+ pregnant' and 'B+ lactating' women were more likely to be lost in the first year (57% vs. 56.9% vs. 31.6%; P < 0.001) and to have no follow-up after the first visit (42.4% vs. 29.2% vs. 16.4%; P < 0.001) than 'own health' women. In adjusted analyses, risk of being lost to follow-up was higher in 'B+ pregnant' (adjusted subhazard ratio [asHR]: 2.77; 95% CI: 2.18-3.50; P < 0.001) and 'B+ lactating' (asHR: 1.94; 95% CI: 1.37-2.74; P < 0.001). Type 2 health centre was the only additional significant risk factor for loss to follow-up. CONCLUSIONS Retention among PLW starting option B+ ART was poor and mainly driven by early losses. The success of Option B+ for prevention of mother-to-child transmission of HIV in rural settings with weak health systems will depend on specific improvements in counselling and retention measures, especially at the beginning of treatment.
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Affiliation(s)
| | | | | | - Manuel Aly Mussa
- Health Provincial Directorate, Operational Research Nucleus of Pemba, Pemba, Mozambique
| | | | - Olivia Keiser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Gilles Wandeler
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Department of Infectious Diseases, Bern University Hospital, University of Bern, Switzerland
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Chiwaula LS, Chirwa GC, Cataldo F, Kapito-Tembo A, Hosseinipour MC, van Lettow M, Tweya H, Kayoyo V, Khangamwa-Kaunda B, Kasende F, Trapence C, Gugsa S, Rosenberg NE, Eliya M, Phiri S. The value of informal care in the context of option B+ in Malawi: a contingent valuation approach. BMC Health Serv Res 2016; 16:136. [PMID: 27095249 PMCID: PMC4837588 DOI: 10.1186/s12913-016-1381-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 04/12/2016] [Indexed: 12/02/2022] Open
Abstract
Background Informal care, the health care provided by the patient’s social network is important in low income settings although its monetary value is rarely estimated. The lack of estimates of the value of informal care has led to its omission in economic evaluations but this can result in incorrect decisions about cost effectiveness of an intervention. We explore the use of contingent valuation methods of willingness to pay (WTP) and willingness to accept (WTA) to estimate the value of informal care provided to HIV infected women that are accessing antiretroviral therapy (ART) under the Option B+ approach to prevention of mother-to-child transmission (PMTCT) of HIV in Malawi. Methods We collected cross sectional data from 93 caregivers of women that received ART care from six health facilities in Malawi. Caregivers of women that reported for ART care on the survey day and consented to participate in the survey were included until the targeted sample size for the facility was reached. We estimated the value of informal care by using the willingness to accept (WTA) and willingness to pay (WTP) approaches. Medians were used to summarize the values and these were compared by the Wilcoxon signed-rank test. Results The median WTA to provide informal care in a month was US$30 and the median WTP for informal care was US$13 and the two were statistically different (p < 0.000). Median WTP was higher in the urban areas than in the rural areas (US$21 vs. US$13, p < 0.001) and for caregivers from households from higher wealth quintile than in the lower quintile (US$15 vs. US$13, p < 0.0462). Conclusion Informal caregivers place substantial value on informal care giving. In low income settings where most caregivers are not formally employed, WTP and WTA approaches can be used to value informal care. Clinical trial number NCT02005835. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1381-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Michael Eliya
- Department of HIV/AIDS, Ministry of Health, Lilongwe, Malawi
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Comparative cost-effectiveness of Option B+ for prevention of mother-to-child transmission of HIV in Malawi. AIDS 2016; 30:953-62. [PMID: 26691682 DOI: 10.1097/qad.0000000000001009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of prevention of mother-to-child transmission (MTCT) of HIV with lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women ('Option B+') compared with ART during pregnancy or breastfeeding only unless clinically indicated ('Option B'). DESIGN Mathematical modelling study of first and second pregnancy, informed by data from the Malawi Option B+ programme. METHODS Individual-based simulation model. We simulated cohorts of 10 000 women and their infants during two subsequent pregnancies, including the breastfeeding period, with either Option B+ or B. We parameterized the model with data from the literature and by analysing programmatic data. We compared total costs of antenatal and postnatal care, and lifetime costs and disability-adjusted life-years of the infected infants between Option B+ and Option B. RESULTS During the first pregnancy, 15% of the infants born to HIV-infected mothers acquired the infection. With Option B+, 39% of the women were on ART at the beginning of the second pregnancy, compared with 18% with Option B. For second pregnancies, the rates MTCT were 11.3% with Option B+ and 12.3% with Option B. The incremental cost-effectiveness ratio comparing the two options ranged between about US$ 500 and US$ 1300 per DALY averted. CONCLUSION Option B+ prevents more vertical transmissions of HIV than Option B, mainly because more women are already on ART at the beginning of the next pregnancy. Option B+ is a cost-effective strategy for PMTCT if the total future costs and lost lifetime of the infected infants are taken into account.
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Karnon J, Orji N. Option B+ for the prevention of mother-to-child transmission of HIV infection in developing countries: a review of published cost-effectiveness analyses. Health Policy Plan 2016; 31:1133-41. [PMID: 27016949 DOI: 10.1093/heapol/czw025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To review the published literature on the cost effectiveness of Option B+ (lifelong antiretroviral therapy) for preventing mother-to-child transmission (PMTCT) of HIV during pregnancy and breastfeeding to inform decision making in low- and middle-income countries. METHODS PubMed, Scopus, Google scholar and Medline were searched to identify studies of the cost effectiveness of the World Health Organization (WHO) treatment guidelines for PMTCT. Study quality was appraised using the consolidated health economic evaluation reporting standards checklist. Eligible studies were reviewed in detail to assess the relevance and impact of alternative evaluation frameworks, assumptions and input parameter values. RESULTS Five published cost effectiveness analyses of Option B+ for the PMTCT of HIV were identified. The reported cost-effectiveness of Option B+ varies substantially, with the results of different studies implying that Option B+ is dominant (lower costs, greater benefits), cost-effective (additional benefits at acceptable additional costs) or not cost-effective (additional benefits at unacceptable additional costs). This variation is due to significant differences in model structures and input parameter values. Structural differences were observed around the estimation of programme effects on infants, HIV-infected mothers and their HIV negative partners, over multiple pregnancies, as well assumptions regarding routine access to antiretroviral therapies. Significant differences in key input parameters were observed in transmission rates, intervention costs and effects and downstream cost savings. CONCLUSIONS Across five model-based cost-effectiveness analyses of strategies for the PMTCT of HIV, the most comprehensive analysis reported that option B+ is highly likely to be cost-effective. This evaluation may have been overly favourable towards option B+ with respect to some input parameter values, but potentially important additional benefits were omitted. Decision makers might be best advised to review this analysis, with a view to requesting additional analyses of the model to inform local funding decisions around alternative strategies for the PMTCT of HIV.
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Affiliation(s)
| | - Nneka Orji
- and Department of Health Planning, Research and Statistics, Federal Ministry of Health, Nigeria
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Maredza M, Chola L, Hofman K. Economic evaluations of interventions to reduce neonatal morbidity and mortality: a review of the evidence in LMICs and its implications for South Africa. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2016; 14:2. [PMID: 26819571 PMCID: PMC4728765 DOI: 10.1186/s12962-015-0049-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Newborn mortality, comprising a third of all under-5 deaths, has hardly changed in low and middle income countries (LMICs) including South Africa over the past decade. To attain the MDG 4 target, greater emphasis must be placed on wide-scale implementation of proven, cost-effective interventions. This paper reviews economic evidence on effective neonatal health interventions in LMICs from 2000-2013; documents lessons for South African policy on neonatal health; and identifies gaps and areas for future research. METHODS A narrative review was performed in leading public health databases for full economic evaluations conducted between 2000 and 2013. Data extraction from the articles included in the review was guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist, and the quality of the included economic evaluations was assessed using the Quality of Health Economics Studies Instrument (QHES). RESULTS Twenty-seven economic evaluations were identified, from South East Asia and sub-Saharan Africa, with those from sub-Saharan Africa primarily focused on HIV/AIDS. Packages of care to prevent neonatal mortality were more cost-effective than vertical interventions. A wide variability in methodological approaches challenges the comparability of study results between countries. In South Africa, there is limited cost-effectiveness evidence for the interventions proposed by the National Perinatal Morbidity and Mortality Committee. CONCLUSIONS Neonatal strategies have a strong health system focus but this review suggests that strengthening community care could be an additional component for averting neonatal deaths. While some evidence exists, having a more complete understanding of how to most effectively deploy scarce resources for neonatal health in South Africa in the post-2015 era is essential.
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Affiliation(s)
- Mandy Maredza
- />Priority Cost-Effective Lessons for Systems Strengthening-South Africa (PRICELESS SA), Medical Research Council/Wits Rural Public Health and Health Transition Research Unit (Agincourt), Johannesburg, South Africa
- />School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lumbwe Chola
- />Priority Cost-Effective Lessons for Systems Strengthening-South Africa (PRICELESS SA), Medical Research Council/Wits Rural Public Health and Health Transition Research Unit (Agincourt), Johannesburg, South Africa
- />School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- />Priority Cost-Effective Lessons for Systems Strengthening-South Africa (PRICELESS SA), Medical Research Council/Wits Rural Public Health and Health Transition Research Unit (Agincourt), Johannesburg, South Africa
- />School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Figueroa C, Johnson C, Verster A, Baggaley R. Attitudes and Acceptability on HIV Self-testing Among Key Populations: A Literature Review. AIDS Behav 2015; 19:1949-65. [PMID: 26054390 PMCID: PMC4598350 DOI: 10.1007/s10461-015-1097-8] [Citation(s) in RCA: 311] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
HIV self-testing (HIVST) is a potential strategy to overcome disparities in access to and uptake of HIV testing, particularly among key populations (KP). A literature review was conducted on the acceptability, values and preferences among KP. Data was analyzed by country income World Bank classification, type of specimen collection, level of support offered and other qualitative aspects. Most studies identified were from high-income countries and among men who have sex with men (MSM) who found HIVST to be acceptable. In general, MSM were interested in HIVST because of its convenient and private nature. However, they had concerns about the lack of counseling, possible user error and accuracy. Data on the values and preferences of other KP groups regarding HIVST is limited. This should be a research priority, as HIVST is likely to become more widely available, including in resource-limited settings.
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Herce ME, Mtande T, Chimbwandira F, Mofolo I, Chingondole CK, Rosenberg NE, Lancaster KE, Kamanga E, Chinkonde J, Kumwenda W, Tegha G, Hosseinipour MC, Hoffman IF, Martinson FE, Stein E, van der Horst CM. Supporting Option B+ scale up and strengthening the prevention of mother-to-child transmission cascade in central Malawi: results from a serial cross-sectional study. BMC Infect Dis 2015; 15:328. [PMID: 26265222 PMCID: PMC4533797 DOI: 10.1186/s12879-015-1065-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We established Safeguard the Family (STF) to support Ministry of Health (MoH) scale-up of universal antiretroviral therapy (ART) for HIV-infected pregnant and breastfeeding women (Option B+) and to strengthen the prevention of mother-to-child transmission (PMTCT) cascade from HIV testing and counseling (HTC) through maternal ART provision and post-delivery early infant HIV diagnosis (EID). To these ends, we implemented the following interventions in 5 districts: 1) health worker training and mentorship; 2) couples' HTC and male partner involvement; 3) women's psychosocial support groups; and 4) health and laboratory system strengthening for EID. METHODS We conducted a serial cross-sectional study using facility-level quarterly (Q) program data and individual-level infant HIV-1 DNA PCR data to evaluate STF performance on PMTCT indicators for project years (Y) 1 (April-December 2011) through 3 (January-December 2013), and compared these results to national averages. RESULTS Facility-level uptake of HTC, ART, infant nevirapine prophylaxis, and infant DNA PCR testing increased significantly from quarterly baselines of 66 % (n/N = 32,433/48,804), 23 % (n/N = 442/1,958), 1 % (n/N = 10/1,958), and 52 % (n/N = 1,385/2,644) to 87 % (n/N = 39,458/45,324), 96 % (n/N = 2,046/2,121), 100 % (n/N = 2,121/2,121), and 62 % (n/N = 1,462/2,340), respectively, by project end (all p < 0.001). Quarterly HTC, ART, and infant nevirapine prophylaxis uptake outperformed national averages over years 2-3. While transitioning EID laboratory services to MoH, STF provided first-time HIV-1 DNA PCR testing for 2,226 of 11,261 HIV-exposed infants (20 %) tested in the MoH EID program in STF districts from program inception (Y2) through Y3. Of these, 78 (3.5 %) tested HIV-positive. Among infants with complete documentation (n = 608), median age at first testing decreased from 112 days (interquartile range, IQR: 57-198) in Y2 to 76 days (IQR: 46-152) in Y3 (p < 0.001). During Y3 (only year with national data for comparison), non-significantly fewer exposed infants tested HIV-positive (3.6 %) at first testing in STF districts than nationally (4.1 %) (p = 0.4). CONCLUSIONS STF interventions, integrated within the MoH Option B+ program, achieved favorable HTC, maternal ART, infant prophylaxis, and EID services uptake, and a low proportion of infants found HIV-infected at first DNA PCR testing. Continued investments are needed to strengthen the PMTCT cascade, particularly around EID.
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Affiliation(s)
- Michael E Herce
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Tiwonge Mtande
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | - Frank Chimbwandira
- HIV Unit, Ministry of Health, Government of the Republic of Malawi, P.O. Box 30377, Lilongwe 3, Malawi.
| | - Innocent Mofolo
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | | | - Nora E Rosenberg
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Kathy E Lancaster
- University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Esmie Kamanga
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | | | - Wiza Kumwenda
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | - Gerald Tegha
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | - Mina C Hosseinipour
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Irving F Hoffman
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Francis E Martinson
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Eva Stein
- University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Charles M van der Horst
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
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Enarson PM, Gie RP, Mwansambo CC, Chalira AE, Lufesi NN, Maganga ER, Enarson DA, Cameron NA, Graham SM. Potentially Modifiable Factors Associated with Death of Infants and Children with Severe Pneumonia Routinely Managed in District Hospitals in Malawi. PLoS One 2015; 10:e0133365. [PMID: 26237222 PMCID: PMC4523211 DOI: 10.1371/journal.pone.0133365] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 06/26/2015] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To investigate recognised co-morbidities and clinical management associated with inpatient pneumonia mortality in Malawian district hospitals. METHODS Prospective cohort study, of patient records, carried out in Malawi between 1st October 2000 and 30th June 2003. The study included all children aged 0-59 months admitted to the paediatric wards in sixteen district hospitals throughout Malawi with severe and very severe pneumonia. We compared individual factors between those that survived (n = 14 076) and those that died (n = 1 633). RESULTS From logistic regression analysis, predictors of death in hospital, adjusted for age, sex and severity grade included comorbid conditions of meningitis (OR =2.49, 95% CI 1.50-4.15), malnutrition (OR =2.37, 95% CI 1.94-2.88) and severe anaemia (OR =1.41, 95% CI 1.03-1.92). Requiring supplementary oxygen (OR =2.16, 95% CI 1.85-2.51) and intravenous fluids (OR =3.02, 95% CI 2.13-4.28) were associated with death while blood transfusion was no longer significant (OR =1.10, 95% CI 0.77-1.57) when the model included severe anaemia. CONCLUSIONS This study identified a number of challenges to improve outcome for Malawian infants and children hospitalised with pneumonia. These included improved assessment of co-morbidities and more rigorous application of standard case management.
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Affiliation(s)
- Penelope M. Enarson
- International Union Against Tuberculosis and Lung Disease, Paris, France
- Desmond Tutu TB Centre, Stellenbosch University, Tygerberg, South Africa
- * E-mail:
| | - Robert P. Gie
- Desmond Tutu TB Centre, Stellenbosch University, Tygerberg, South Africa
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | | | | | | | | | - Donald A. Enarson
- International Union Against Tuberculosis and Lung Disease, Paris, France
- Desmond Tutu TB Centre, Stellenbosch University, Tygerberg, South Africa
| | - Neil A. Cameron
- Division of Community Health, The Department of Interdisciplinary Sciences, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | - Stephen M. Graham
- International Union Against Tuberculosis and Lung Disease, Paris, France
- Centre for International Child Health, University of Melbourne Department of Paediatrics and Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, Australia
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Efficacy of WHO recommendation for continued breastfeeding and maternal cART for prevention of perinatal and postnatal HIV transmission in Zambia. J Int AIDS Soc 2015; 18:19352. [PMID: 26140453 PMCID: PMC4490793 DOI: 10.7448/ias.18.1.19352] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 03/08/2015] [Accepted: 04/13/2015] [Indexed: 12/15/2022] Open
Abstract
Introduction To prevent mother-to-child transmission (MTCT) of HIV in developing countries, new World Health Organization (WHO) guidelines recommend maternal combination antiretroviral therapy (cART) during pregnancy, throughout breastfeeding for 1 year and then cessation of breastfeeding (COB). The efficacy of this approach during the first six months of exclusive breastfeeding has been demonstrated, but the efficacy of this approach beyond six months is not well documented. Methods A prospective observational cohort study of 279 HIV-positive mothers was started on zidovudine/3TC and lopinavir/ritonavir tablets between 14 and 30 weeks gestation and continued indefinitely thereafter. Women were encouraged to exclusively breastfeed for six months, complementary feed for the next six months and then cease breastfeeding between 12 and 13 months. Infants were followed for transmission to 18 months and for survival to 24 months. Text message reminders and stipends for food and transport were utilized to encourage adherence and follow-up. Results Total MTCT was 9 of 219 live born infants (4.1%; confidence interval (CI) 2.2–7.6%). All breastfeeding transmissions that could be timed (5/5) occurred after six months of age. All mothers who transmitted after six months had a six-month plasma viral load >1,000 copies/ml (p<0.001). Poor adherence to cART as noted by missed dispensary visits was associated with transmission (p=0.04). Infant mortality was lower after six months of age than during the first six months of life (p=0.02). The cumulative rate of infant HIV infection or death at 18 months was 29/226 (12.8% 95 CI: 7.5–20.8%). Conclusions Maternal cART may limit MTCT of HIV to the UNAIDS target of <5% for eradication of paediatric HIV within the context of a clinical study, but poor adherence to cART and follow-up can limit the benefit. Continued breastfeeding can prevent the rise in infant mortality after six months seen in previous studies, which encouraged early COB.
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Goldhaber-Fiebert JD, Brandeau ML. Evaluating Cost-effectiveness of Interventions That Affect Fertility and Childbearing: How Health Effects Are Measured Matters. Med Decis Making 2015; 35:818-46. [PMID: 25926281 DOI: 10.1177/0272989x15583845] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 04/01/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Current guidelines for economic evaluations of health interventions define relevant outcomes as those accruing to individuals receiving interventions. Little consensus exists on counting health impacts on current and future fertility and childbearing. Our objective was to characterize current practices for counting such health outcomes. METHODS We developed a framework characterizing health interventions with direct and/or indirect effects on fertility and childbearing and how such outcomes are reported. We identified interventions spanning the framework and performed a targeted literature review for economic evaluations of these interventions. For each article, we characterized how the potential health outcomes from each intervention were considered, focusing on quality-adjusted life-years (QALYs) associated with fertility and childbearing. RESULTS We reviewed 108 studies, identifying 7 themes: 1) Studies were heterogeneous in reporting outcomes. 2) Studies often selected outcomes for inclusion that tend to bias toward finding the intervention to be cost-effective. 3) Studies often avoided the challenges of assigning QALYs for pregnancy and fertility by instead considering cost per intermediate outcome. 4) Even for the same intervention, studies took heterogeneous approaches to outcome evaluation. 5) Studies used multiple, competing rationales for whether and how to include fertility-related QALYs and whose QALYs to include. 6) Studies examining interventions with indirect effects on fertility typically ignored such QALYs. 7) Even recent studies had these shortcomings. Limitations include that the review was targeted rather than systematic. CONCLUSIONS Economic evaluations inconsistently consider QALYs from current and future fertility and childbearing in ways that frequently appear biased toward the interventions considered. As the Panel on Cost-Effectiveness in Health and Medicine updates its guidelines, making the practice of cost-effectiveness analysis more consistent is a priority. Our study contributes to harmonizing methods in this respect.
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Affiliation(s)
- Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA (JDGF)
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA (MLB)
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VanDeusen A, Paintsil E, Agyarko-Poku T, Long EF. Cost effectiveness of option B plus for prevention of mother-to-child transmission of HIV in resource-limited countries: evidence from Kumasi, Ghana. BMC Infect Dis 2015; 15:130. [PMID: 25887574 PMCID: PMC4374181 DOI: 10.1186/s12879-015-0859-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 02/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Achieving the goal of eliminating mother-to-child HIV transmission (MTCT) necessitates increased access to antiretroviral therapy (ART) for HIV-infected pregnant women. Option B provides ART through pregnancy and breastfeeding, whereas Option B+ recommends continuous ART regardless of CD4 count, thus potentially reducing MTCT during future pregnancies. Our objective was to compare maternal and pediatric health outcomes and cost-effectiveness of Option B+ versus Option B in Ghana. METHODS A decision-analytic model was developed to simulate HIV progression in mothers and transmission (in utero, during birth, or through breastfeeding) to current and all future children. Clinical parameters, including antenatal care access and fertility rates, were estimated from a retrospective review of 817 medical records at two hospitals in Ghana. Additional parameters were obtained from published literature. Modeled outcomes include HIV infections averted among newborn children, quality-adjusted life-years (QALYs), and cost-effectiveness ratios. RESULTS HIV-infected women in Ghana have a lifetime average of 2.3 children (SD 1.3). Projected maternal life expectancy under Option B+ is 16.1 years, versus 16.0 years with Option B, yielding a gain of 0.1 maternal QALYs and 3.2 additional QALYs per child. Despite higher initial ART costs, Option B+ costs $785/QALY gained, a value considered very cost-effective by World Health Organization benchmarks. Widespread implementation of Option B+ in Ghana could theoretically prevent up to 668 HIV infections among children annually. Cost-effectiveness estimates remained favorable over robust sensitivity analyses. CONCLUSIONS Although more expensive than Option B, Option B+ substantially reduces MTCT in future pregnancies, increases both maternal and pediatric QALYs, and is a cost-effective use of limited resources in Ghana.
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Affiliation(s)
- Adam VanDeusen
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA.
| | - Elijah Paintsil
- Departments of Pediatrics & Pharmacology, Yale School of Medicine, Yale Child Health Research Center, 464 Congress Ave, New Haven, CT, USA.
| | - Thomas Agyarko-Poku
- Department of Pharmacy, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Elisa F Long
- University of California Los Angeles, Anderson School of Management, Los Angeles, CA, USA.
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Lessons learned from early implementation of option B+: the Elizabeth Glaser Pediatric AIDS Foundation experience in 11 African countries. J Acquir Immune Defic Syndr 2015; 67 Suppl 4:S188-94. [PMID: 25436817 PMCID: PMC4251909 DOI: 10.1097/qai.0000000000000372] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background: “Option B+” is a World Health Organization-recommended approach to prevent mother-to-child HIV transmission whereby all HIV-positive pregnant and lactating women initiate lifelong antiretroviral therapy (ART). This review of early Option B+ implementation experience is intended to inform Ministries of Health and others involved in implementing Option B+. Methods: This implementation science study analyzed data from 11 African countries supported by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to describe early experience implementing Option B+. Data are from 4 sources: (1) national guidelines for prevention of mother-to-child HIV transmission and Option B+ implementation plans, (2) aggregated service delivery data between January 2013 and March 2014 from EGPAF-supported sites, (3) field visits to Option B+ implementation sites, and (4) relevant EGPAF research, quality improvement, and evaluation studies. Results: Rapid adoption of Option B+ led to large increases in percentage of HIV-positive pregnant women accessing ART in antenatal care. By the end of 2013, most programs reached at least 50% of HIV-positive women in antenatal care with ART, even in countries using a phased approach to implementation. Scaling up Option B+ through integrating ART in maternal and child health settings has required expansion of the workforce, and task shifting to allow nurse-led ART initiation has created staffing pressure on lower-level cadres for counseling and community follow-up. Complex data collection needs may be impairing data quality. Discussion: Early experiences with Option B+ implementation demonstrate promise. Continued program evaluation is needed, as is specific attention to counseling and support around initiation of lifetime ART in the context of pregnancy and lactation.
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Floridia M, Guaraldi G, Ravizza M, Tibaldi C, Pinnetti C, Maccabruni A, Molinari A, Liuzzi G, Alberico S, Meloni A, Rizzi L, Dalzero S, Tamburrini E. Is "option B+" also being adopted in pregnant women in high-income countries? Temporal trends from a national study in Italy. Clin Infect Dis 2015; 60:159-61. [PMID: 25230994 DOI: 10.1093/cid/ciu736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Marco Floridia
- Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome
| | - Giovanni Guaraldi
- Department of Medical and Surgical Sciences for Children & Adults, University of Modena and Reggio Emilia
| | - Marina Ravizza
- Department of Obstetrics and Gynaecology, DMSD San Paolo Hospital Medical School, University of Milan
| | - Cecilia Tibaldi
- Department of Obstetrics and Neonatology, Città della Salute e della Scienza Hospital, and Universiy of Turin
| | | | - Anna Maccabruni
- Infectious Diseases, University of Pavia, IRCCS Policlinico San Matteo
| | - Atim Molinari
- Department of Infectious Diseases and Hepatology, Azienda Ospedaliera di Parma
| | | | | | - Alessandra Meloni
- Division of Gynaecology and Obstetrics, S. Giovanni di Dio Hospital and University of Cagliari
| | - Laura Rizzi
- Infectious and Tropical Diseases Unit, General Hospital, Varese
| | - Serena Dalzero
- Department of Obstetrics and Gynaecology, DMSD San Paolo Hospital Medical School, University of Milan
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Some EN, Meda N. Does the national program of prevention of mother to child transmission of HIV (PMTCT) reach its target in Ouagadougou, Burkina Faso? Afr Health Sci 2014; 14:889-98. [PMID: 25834498 PMCID: PMC4370068 DOI: 10.4314/ahs.v14i4.17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In the context of universal access to prevention, treatment, care and support, each country has to ensure that 80% of women and children in need have access to PMTCT interventions. OBJECTIVE To assess the PMTCT program achievement in Ouagadougou, the capital city of Burkina Faso. METHODS Between August and October 2008, a cross sectional study was carried out in the five health districts of the Centre Health Region. We reviewed weekly statistics from all health care centres (HCC) to compute the coverage of PMTCT program. In 38 HCC with functional PMTCT program, we extracted data of interest from HCC registers and made direct observations of PMTCT services. RESULTS The PMTCT program was implemented in 49% of HCC (target for the national program: 70%). Fifteen to 31% of these centers were often in shortage for PMTCT consumables. Patients' privacy was not observed in 67% of Voluntary Counselling & HIV Testing wards. Care providers were not qualified enough to deliver PMTCT services. Vitamin A supplementation was not implemented. None of the facilities offered the whole package of PMTCT program interventions. HCC providing HIV testing in labour or in postnatal ward were consistently lacking. Only 86% of antenatal care new attendants benefited from pre-test counselling; 2.4% of pretested women were HIV-positive and 39% of positive mothers received antiretroviral prophylaxis. CONCLUSION Coverage and quality of PMTCT programme in the Centre Health Region in Burkina Faso are still limited. Particular support is needed for training, supervision and infrastructures upgrading.
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Affiliation(s)
- Eric N Some
- Health Research Institute (IRSS) Burkina Faso, Department of Public Health and Biology
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Antiretroviral drugs for prevention of mother-to-child transmission: pharmacologic considerations for a public health approach. AIDS 2014; 28:2551-63. [PMID: 25574958 DOI: 10.1097/qad.0000000000000439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Efavirenz-based antiretroviral therapy is recommended for prevention of mother-to-child transmission of HIV with two programmatic options: lifelong therapy for all women or treatment until cessation of breastfeeding. However, the risk of HIV resistance emerging after discontinuing efavirenz-based antiretroviral therapy is unclear. We review present knowledge surrounding the emergence of resistance after stopping efavirenz-based antiretroviral regimens. DESIGN An expert review. METHODS A literature review was conducted to identify studies assessing risk for emergence of efavirenz-related resistance following discontinuation of efavirenz-based antiretroviral regimens containing either lamivudine and zidovudine or tenofovir disoproxil fumarate and lamivudine. Discontinuation strategies including the use of 'pharmacologic tails' are discussed in the light of what is known about the pharmacology of the drugs. RESULTS We found no head-to-head comparisons between zidovudine, lamivudine and efavirenz and tenofovir disoproxil fumarate, lamivudine and efavirenz. The risk for HIV resistance exists, even with a 5-7 day tail of zidovudine and lamivudine. For tenofovir disoproxil fumarate, lamivudine and efavirenz, we found no clinical data to inform a recommendation for a tail. CONCLUSION In order to prevent emergence of resistance, a tail of at least 2 weeks in duration may be required when discontinuing efavirenz in a regimen containing zidovudine and lamivudine. Studies are needed to characterize the risk of resistance among women who discontinue tenofovir disoproxil fumarate, lamivudine and efavirenz.
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Kastner J, Matthews LT, Flavia N, Bajunirwe F, Erikson S, Berry NS, Kaida A. Antiretroviral Therapy Helps HIV-Positive Women Navigate Social Expectations for and Clinical Recommendations against Childbearing in Uganda. AIDS Res Treat 2014; 2014:626120. [PMID: 25328693 PMCID: PMC4189848 DOI: 10.1155/2014/626120] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 08/30/2014] [Accepted: 09/05/2014] [Indexed: 11/17/2022] Open
Abstract
Understanding factors that influence pregnancy decision-making and experiences among HIV-positive women is important for developing integrated reproductive health and HIV services. Few studies have examined HIV-positive women's navigation through the social and clinical factors that shape experiences of pregnancy in the context of access to antiretroviral therapy (ART). We conducted 25 semistructured interviews with HIV-positive, pregnant women receiving ART in Mbarara, Uganda in 2011 to explore how access to ART shapes pregnancy experiences. Main themes included: (1) clinical counselling about pregnancy is often dissuasive but focuses on the importance of ART adherence once pregnant; (2) accordingly, women demonstrate knowledge about the role of ART adherence in maintaining maternal health and reducing risks of perinatal HIV transmission; (3) this knowledge contributes to personal optimism about pregnancy and childbearing in the context of HIV; and (4) knowledge about and adherence to ART creates opportunities for HIV-positive women to manage normative community and social expectations of childbearing. Access to ART and knowledge of the accompanying lowered risks of mortality, morbidity, and HIV transmission improved experiences of pregnancy and empowered HIV-positive women to discretely manage conflicting social expectations and clinical recommendations regarding childbearing.
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Affiliation(s)
- Jasmine Kastner
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Room 10522, 8888 University Drive, Burnaby, BC, Canada V5A 1S6
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lynn T. Matthews
- Massachusetts General Hospital (MGH), Center for Global Health, Boston, MA 02114, USA
- Division of Infectious Disease, MGH, Boston, MA 02114, USA
| | - Ninsiima Flavia
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Susan Erikson
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Room 10522, 8888 University Drive, Burnaby, BC, Canada V5A 1S6
| | - Nicole S. Berry
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Room 10522, 8888 University Drive, Burnaby, BC, Canada V5A 1S6
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Room 10522, 8888 University Drive, Burnaby, BC, Canada V5A 1S6
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Sinunu MA, Schouten EJ, Wadonda-Kabondo N, Kajawo E, Eliya M, Moyo K, Chimbwandira F, Strunin L, Kellerman SE. Evaluating the impact of prevention of mother-to-child transmission of HIV in Malawi through immunization clinic-based surveillance. PLoS One 2014; 9:e100741. [PMID: 24968298 PMCID: PMC4072708 DOI: 10.1371/journal.pone.0100741] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 05/30/2014] [Indexed: 12/02/2022] Open
Abstract
Background Prevention of mother-to-child transmission of HIV (PMTCT) programs can greatly reduce the vertical transmission rate (VTR) of HIV, and Malawi is expanding PMTCT access by offering HIV-infected pregnant women life-long antiretroviral therapy (Option B+). There is currently no empirical data on the effectiveness of Malawian PMTCT programs. This study describes a surveillance approach to obtain population-based estimates of the VTR of infants <3 months of age in Malawi immediately after the adoption of Option B+. Methods and Findings A sample of caregivers and infants <3 months from 53 randomly chosen immunization clinics in 4 districts were enrolled. Infant dried blood spot (DBS) samples were tested for HIV exposure with an antibody test to determine maternal seropositivity. Positive samples were further tested using DNA PCR to determine infant infection status and VTR. Caregivers were surveyed about maternal receipt of PMTCT services. Of the 5,068 DBS samples, 764 were ELISA positive indicating 15.1% (14.1–16.1%) of mothers were HIV-infected and passed antibodies to their infant. Sixty-five of the ELISA-positive samples tested positive by DNA PCR, indicating a vertical transmission rate of 8.5% (6.6–10.7%). Survey data indicates 64.8% of HIV-infected mothers and 46.9% of HIV-exposed infants received some form of antiretroviral prophylaxis. Results do not include the entire breastfeeding period which extends to almost 2 years in Malawi. Conclusions The observed VTR was lower than expected given earlier modeled estimates, suggesting that Malawi’s PMTCT program has been successful at averting perinatal HIV transmission. Challenges to full implementation of PMTCT remain, particularly around low reported antiretroviral prophylaxis. This approach is a useful surveillance tool to assess changes in PMTCT effectiveness as Option B+ is scaled-up, and can be expanded to track programming effectiveness for young infants over time in Malawi and elsewhere.
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Affiliation(s)
- Michele A. Sinunu
- Boston University School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | | | | | - Enock Kajawo
- Management Sciences for Health, Lilongwe, Malawi
| | | | | | | | - Lee Strunin
- Boston University School of Public Health, Boston, Massachusetts, United States of America
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Price AJ, Kayange M, Zaba B, Chimbwandira FM, Jahn A, Chirwa Z, Dasgupta AN, Katundu C, Saul JL, Glynn JR, Koole O, Crampin AC. Uptake of prevention of mother-to-child-transmission using Option B+ in northern rural Malawi: a retrospective cohort study. Sex Transm Infect 2014; 90:309-14. [PMID: 24714445 PMCID: PMC4033143 DOI: 10.1136/sextrans-2013-051336] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
To identify points of dropout on the pathway from offering HIV testing to maintenance on antiretroviral therapy (ART), following the introduction of the Option B+ policy for pregnant women in Malawi (lifelong ART for HIV-positive mothers and 6 weeks nevirapine for the infants), a retrospective cohort study within a demographic surveillance system in northern Malawi. Women living in the demographic surveillance system who initiated antenatal care (ANC) between July 2011 (date of policy change) and January 2013, were eligible for inclusion. Women who consented were interviewed at home about their health facility attendance and care since pregnancy, including antenatal clinic (ANC) visits, delivery and postpartum care. Women's reports, patient-held health records and clinic health records were manually linked to ascertain service use. Among 395 women, 86% had tested for HIV before the pregnancy, 90% tested or re-tested at the ANC visit, and <1% had never tested. Among 53 mothers known to be HIV-positive before attending ANC, 15 (28%) were already on ART prior to pregnancy. Ten women tested HIV-positive for the first time during pregnancy. Of the 47 HIV-positive mothers not already on ART, 26/47 (55%) started treatment during pregnancy. All but five women who started ART were still on treatment at the time of study interview. HIV testing was almost universal and most women who initiated ART were retained in care. However, nearly half of eligible pregnant women not on ART at the start of ANC had not taken up the invitation to initiate (lifelong) ART by the time of delivery, leaving their infants potentially HIV-exposed.
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Affiliation(s)
- Alison J Price
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Basia Zaba
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | | | - Judith R Glynn
- London School of Hygiene and Tropical Medicine, London, UK
| | - Olivier Koole
- London School of Hygiene and Tropical Medicine, London, UK
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Zulliger R, Black S, Holtgrave DR, Ciaranello AL, Bekker LG, Myer L. Cost-effectiveness of a package of interventions for expedited antiretroviral therapy initiation during pregnancy in Cape Town, South Africa. AIDS Behav 2014; 18:697-705. [PMID: 24122044 DOI: 10.1007/s10461-013-0641-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Initiating antiretroviral therapy (ART) early in pregnancy is an important component of effective interventions to prevent the mother-to-child transmission of HIV (PMTCT). The rapid initiation of ART in pregnancy(RAP) program was a package of interventions to expedite ART initiation in pregnant women in Cape Town, South Africa. Retrospective cost-effectiveness, sensitivity and threshold analyses were conducted of the RAP program to determine the cost-utility thresholds for rapid initiation of ART in pregnancy. Costs were drawn from a detailed micro-costing of the program. The overall programmatic cost was US$880 per woman and the base case cost-effectiveness ratio was US$1,160 per quality-adjusted lifeyear (QALY) saved. In threshold analyses, the RAP program remained cost-effective if mother-to-child transmission was reduced by C0.33 %; if C1.76 QALY were saved with each averted perinatal infection; or if RAP-related costs were under US$4,020 per woman. The package of rapid initiation services was very cost-effective, as compared to standard services in this setting. Threshold analyses demonstrated that the intervention required minimal reductions in perinatal infections in order to be cost-effective. Interventions for the rapid initiation of ART in pregnancy hold considerable potential as a cost-effective use of limited resources for PMTCT in sub-Saharan Africa.
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Ishikawa N, Shimbo T, Miyano S, Sikazwe I, Mwango A, Ghidinelli MN, Syakantu G. Health outcomes and cost impact of the new WHO 2013 guidelines on prevention of mother-to-child transmission of HIV in Zambia. PLoS One 2014; 9:e90991. [PMID: 24604067 PMCID: PMC3946295 DOI: 10.1371/journal.pone.0090991] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 02/07/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Countries are currently progressing towards the elimination of new paediatric HIV infections by 2015. WHO published new consolidated guidelines in June 2013, which now recommend either 'Antiretroviral drugs (ARVs) for women living with HIV during pregnancy and breastfeeding (Option B)' or 'Lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women living with HIV (Option B+)', while de facto phasing out Option A. This study examined health outcomes and cost impact of the shift to WHO 2013 recommendations in Zambia. METHODS A decision analytic model was developed based on the national health system perspective. Estimated risk and number of cases of HIV transmission to infants and to serodiscordant partners, and proportions of HIV-infected pregnant women with CD4 count of ≤350 cells/mm3 to initiate ART were compared between 2010 Option A and the 2013 recommendations. Total costs of prevention of mother-to-child transmission of HIV (PMTCT) services per annual cohort of pregnant women, incremental cost-effectiveness ratio (ICER) per infection averted and quality-adjusted life-year (QALY) gained were examined. RESULTS Our analysis suggested that the shift from 2010 Option A to the 2013 guidelines would result in a 33% reduction of the risk of HIV transmission among exposed infants. The risk of transmission to serodiscordant partners for a period of 24 months would be reduced by 72% with 'ARVs during pregnancy and breastfeeding' and further reduced by 15% with 'Lifelong ART'. The probability of HIV-infected pregnant women to initiate ART would increase by 80%. It was also suggested that while the shift would generate higher PMTCT costs, it would be cost-saving in the long term as it spares future treatment costs by preventing infections in infants and partners. CONCLUSION The shift to the WHO 2013 guidelines in Zambia would positively impact health of family and save future costs related to care and treatment.
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Affiliation(s)
- Naoko Ishikawa
- National Center for Global Health and Medicine, Tokyo, Japan
| | - Takuro Shimbo
- National Center for Global Health and Medicine, Tokyo, Japan
| | - Shinsuke Miyano
- National Center for Global Health and Medicine, Tokyo, Japan
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Risks and benefits of lifelong antiretroviral treatment for pregnant and breastfeeding women: a review of the evidence for the Option B+ approach. Curr Opin HIV AIDS 2014; 8:474-89. [PMID: 23925003 DOI: 10.1097/coh.0b013e328363a8f2] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Considerable debate has emerged on whether Option B+ (B+), initiation of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, is the best approach to achieving elimination of mother-to-child-transmission. However, direct evidence and experience with B+ is limited. We review the current evidence informing the proposed benefits and potential risks of the B+ approach, distinguishing individual health concerns for mother and child from program delivery and public health issues. RECENT FINDINGS For mothers and infants, B+ may offer significant benefits for transmission prevention and maternal health. However, several studies raise concerns about the safety of ART exposure to fetuses and infants, as well as adherence challenges for pregnant and breastfeeding mothers. For program delivery and public health, B+ presents distinct advantages in terms of transmission prevention to uninfected partners and increased simplicity potentially improving program feasibility, access, uptake, and retention in care. Despite being more costly in the short-term, B+ will likely be cost effective over time. SUMMARY This review provides a detailed analysis of risks and benefits of B+. As national programs adopt this approach, it will be critical to carefully assess both short-term and long-term maternal and infant outcomes.
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