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Clinical impact and cost-effectiveness of early infant HIV diagnosis in South Africa: Test timing and frequency
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Journal of Infectious Diseases Advance Access published August 17, 2016
Jordan A. Francke1,2, Martina Penazzato3,4, Taige Hou1,2, Elaine J. Abrams5, Rachel L. MacLean1,2, Landon Myer6, Rochelle P. Walensky1,2,7,8,9, Valériane Leroy10, Milton C. Weinstein11,12, Robert A. Parker1,2,9,12,13, Kenneth A. Freedberg1,2,7,9,11, Andrea Ciaranello2,7
Abstract
Background. Early infant HIV diagnosis (EID) and antiretroviral therapy dramatically reduce mortality. EID is recommended at six weeks of age, but many infant infections are missed.
Design/Methods. We simulated four EID strategies for HIV-exposed infants in South Africa: no EID (diagnosis only after illness), testing once (birth alone; 6 weeks alone) and twice (birth and 6 weeks). We calculated incremental cost-effectiveness ratios (ICERs) using discounted costs and life expectancies for all HIV-exposed (infected and uninfected) infants.
Results. In the base case (guideline-concordant care), no EID produced a life expectancy of 21.1y (HIV-infected) and 61.1y (HIV-exposed); lifetime cost averaged $1,430/HIV-exposed infant.
The birth and 6 weeks strategy maximized life expectancy (HIV-infected: 26.5y; HIV-exposed: 61.4y), costing $1,840/infant tested. The ICER of 6 weeks alone vs. no EID was $1,250/year of life saved (YLS, 19% of South Africa's per-capita GDP); birth and 6 weeks vs. 6 weeks alone was $2,900/YLS (45% of GDP). Increasing result-return and linkage to ART with 6 weeks alone improved survival more than adding a second test.
Conclusions. EID at birth and 6 weeks improves outcomes and is cost-effective, compared to 6 weeks alone. If scale-up costs are comparable, programs should add birth testing after strengthening 6-week testing programs.
Changes to current 6-week EID testing have been proposed, based on the fact that infants who areinfected in utero have detectable virus at birth, but infants infected during delivery (intrapartum) orthrough breastfeeding (postpartum) have detectable virus only several weeks post-infection (8, 9, 12, 13).Infant antiretroviral prophylaxis - usually offered for 6 weeks after birth - could plausibly reduce NATsensitivity at 6 weeks, although data remain equivocal (9, 14).
Lilian and colleagues suggest that testing atbirth, when most infants are in healthcare facilities, or 10 weeks, after infant prophylaxis has ended, mayidentify more HIV-infected children than testing once at 6 weeks (9, 15).
Second, a guideline-concordant program offering EID twice at birth and 6 weeks will further improvesurvival and be cost-effective in South Africa, compared to a 6 weeks alone program, under mostscenarios (Figure 2).
African national estimates (40), Table 2). The no EID strategy (ART only for those surviving andpresenting with an OI) led to the lowest projected survival for HIV-infected infants: 1-year survival64.6%; life expectancy 21.1 years. In the base case (100% testing, result-return, and linkage), survivalsubstantially increased with any EID program. Of the testing-once strategies, survival for HIV-infectedinfants was lower with birth alone (1-year survival 72.0%, life expectancy 24.4 years) than with 6 weeksalone (1-year survival 74.9%, life expectancy 25.9 years), due to the proportion of infants surviving withdetectable virus at each age (Supplemental Figure B). Testing twice further increased survival: birth and 6weeks led to 1-year survival of 76.6% and life expectancy of 26.5 years. The impact of any EID strategyfor the entire birth cohort (HIV-exposed/uninfected and HIV-infected infants) was modest: 1-yearsurvival ranged from 92.7-93.3% and life expectancy from 61.1-61.4 years (Table 2).
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