Is universal antenatal HIV testing still cost-effective?

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.

Ishikawa N, Dalal S, Johnson C, Hogan DR, Shimbo T, Shaffer N, Pendse RN, Lo YR, Ghidinelli MN, Baggaley R. J Int AIDS Soc. 2016 Dec 14;19(1):21212. doi: 10.7448/IAS.19.1.21212. eCollection 2016.

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.

Abstract [1]  Full-text [free] access  [2]

Editor’s notes: This paper describes research undertaken to support the consolidated guidelines on HIV testing services, published by World Health Organization in 2015. This analysis was conducted in response to growing questions as to whether focused HIV testing in high prevalence areas can improve value for money in investment for HIV testing.

A model was parameterized to represent four scenarios with high, intermediate, low, and very low HIV prevalence settings (Namibia, Kenya, Haiti, and Viet Nam). Three approaches to HIV testing in antenatal care are considered in comparison with current coverage in each setting. These three approaches were: a very focused approach, a targeted approach, and a universal testing approach for all pregnant women.  The authors estimate the costs and effects of each scenario, including the future costs of treating paediatric HIV for 20 years. Universal testing was found to be cost-saving in Namibia, Kenya and Haiti and was found to be cost-effective in Viet Nam ($125 per QALY gained).  The targeted testing approach was also more cost-effective than current coverage in all settings.

The clear policy implication from this analysis is that HIV testing for pregnant women saves both money and lives in the long term. Universal HIV testing in antenatal care can be regarded as a good investment in almost any HIV prevalence setting. However, it is also important to note that targeted testing was more cost-effective than current coverage in all settings. Countries that are currently struggling to provide testing in antenatal care may need to consider factors other than cost-effectiveness in their planning and strategy for scaling up. This is important in order to address HIV at a national scale.  

Africa [7], Asia [8], Latin America [9]
Haiti [10], Kenya [11], Namibia [12], Viet Nam [13]
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