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Cost-Effectiveness of a Package of Interventions for Expedited Antiretroviral Therapy Initiation During Pregnancy in Cape Town, South Africa

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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 life year (QALY) saved. In threshold analyses, the RAP program remained cost-effective if mother-to-child transmission was reduced by ≥0.33 %; if ≥1.76 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.

Resumen

La iniciación de la terapia antirretroviral (TAR) en las primeras etapas del embarazo es un componente importante de las intervenciones eficaces para prevenir la transmisión del VIH de madre a hijo. El programa de la iniciación rápida de TAR durante el embarazo (RAP) era un conjunto de intervenciones para acelerar el inicio del tratamiento en mujeres embarazadas en Cape Town, Sudáfrica. Se realizaron un análisis retrospectivo de la relación costo-rendimiento, la sensibilidad y un análisis del umbral del programa RAP para determinar los umbrales de costo-utilidad de la iniciación rápida de TAR en el embarazo. Los costos fueron extraídos de una micro-costing detallada del programa. El costo total fue US$880 por mujer y la relación costo-efectividad caso base fue de US$1,160 por año de vida ajustados por calidad (AVAC) salvado. En el análisis del umbral, el programa RAP seguía siendo rentable si la transmisión de madre a hijo se redujo en ≥0.33 %; si ≥1.76 AVAC se salvaron con cada infección perinatal evitó; o si los costos relacionados con el RAP fueron menos de US$4,020 por mujer. El conjunto de iniciación rápida era muy rentable, en comparación con servicios estándar en este entorno. Los análisis umbrales demostraron que la intervención necesaria una mínima reducción de infecciones perinatales para ser rentable. Las intervenciones para la iniciación rápida de TAR en el embarazo tienen un potencial considerable como una utilización eficaz de los recursos limitados por PMTCT en áfrica subsahariana.

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Acknowledgements

The study team would like to thank the patients and staff at Hanover Park ANC and the Desmond Tutu HIV Foundation Tutu-Tester team for their passion and commitment. Thanks also to our partners: the Cape Town Metro District Health Services, the Western Cape Provincial Department of Health, WolaNani and mothers2mothers.

Conflicts of Interest and Source of Funding

ALC is supported by NIAID (K01 AI 078754). LM is supported by an International Leadership Award from the Elizabeth Glaser Pediatric Fund. For the remaining authors none were declared.

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Authors and Affiliations

  1. Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21224, USA

    Rose Zulliger & David R. Holtgrave

  2. Desmond Tutu HIV Centre, Institute of Infectious Diseases & Molecular Medicine, University of Cape Town, Cape Town, South Africa

    Samantha Black, Linda-Gail Bekker & Landon Myer

  3. Division of Infectious Disease, Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA

    Andrea L. Ciaranello

  4. Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa

    Landon Myer

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  1. Rose Zulliger
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  2. Samantha Black
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  4. Andrea L. Ciaranello
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  5. Linda-Gail Bekker
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Correspondence to Rose Zulliger.

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Zulliger, R., Black, S., Holtgrave, D.R. et al. Cost-Effectiveness of a Package of Interventions for Expedited Antiretroviral Therapy Initiation During Pregnancy in Cape Town, South Africa. AIDS Behav 18, 697–705 (2014). https://doi.org/10.1007/s10461-013-0641-7

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  • DOI: https://doi.org/10.1007/s10461-013-0641-7

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