Jordan A Francke1,2, Martina Penazzato3,4, Taige Hou1,2, Elaine J Abrams5,6, Rachel L MacLean1,2, Landon Myer7, Rochelle P Walensky1,2,8,9,10, Valériane Leroy11, Milton C Weinstein12,13, Robert A Parker1,2,14,10,13, Kenneth A Freedberg1,2,8,10,12, Andrea Ciaranello2,8. 1. Division of General Internal Medicine. 2. Medical Practice Evaluation Center. 3. Medical Research Council Clinical Trials Unit London, United Kingdom. 4. World Health Organization, Geneva, Switzerland. 5. International Center for AIDS Care and Treatment Program, Mailman School of Public Health. 6. College of Physicians and Surgeons, Columbia University, New York. 7. Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa. 8. Division of Infectious Diseases, Department of Medicine. 9. Division of Infectious Diseases, Brigham and Women's Hospital. 10. Center for AIDS Research, Harvard University. 11. Inserm U1027, University of Toulouse 3, France. 12. Department of Health Policy and Management, Harvard T. H. Chan School of Public Health. 13. Harvard Medical School, Boston, Massachusetts. 14. Biostatistics Center, Massachusetts General Hospital.
Abstract
BACKGROUND: Diagnosis of human immunodeficiency virus (HIV) infection during early infancy (commonly known as "early infant HIV diagnosis" [EID]) followed by prompt initiation of antiretroviral therapy dramatically reduces mortality. EID testing is recommended at 6 weeks of age, but many infant infections are missed. DESIGN/ METHODS: We simulated 4 EID testing strategies for HIV-exposed infants in South Africa: no EID (diagnosis only after illness; hereafter, "no EID"), testing once (at birth alone or at 6 weeks of age alone; hereafter, "birth alone" and "6 weeks alone," respectively), and testing twice (at birth and 6 weeks of age; hereafter "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), the no EID strategy produced a life expectancy of 21.1 years (in the HIV-infected group) and 61.1 years (in the HIV-exposed group); lifetime cost averaged $1430/HIV-exposed infant. The birth and 6 weeks strategy maximized life expectancy (26.5 years in the HIV-infected group and 61.4 years in the HIV-exposed group), costing $1840/infant tested. The ICER of the 6 weeks alone strategy versus the no EID strategy was $1250/year of life saved (19% of South Africa's per capita gross domestic product); the ICER for the birth and 6 weeks strategy versus the 6 weeks alone strategy was $2900/year of life saved (45% of South Africa's per capita gross domestic product). Increasing the proportion of caregivers who receive test results and the linkage of HIV-positive infants to antiretroviral therapy with the 6 weeks alone strategy improved survival more than adding a second test. CONCLUSIONS: EID at birth and 6 weeks improves outcomes and is cost-effective, compared with EID at 6 weeks alone. If scale-up costs are comparable, programs should add birth testing after strengthening 6-week testing programs.
BACKGROUND: Diagnosis of human immunodeficiency virus (HIV) infection during early infancy (commonly known as "early infantHIV diagnosis" [EID]) followed by prompt initiation of antiretroviral therapy dramatically reduces mortality. EID testing is recommended at 6 weeks of age, but many infant infections are missed. DESIGN/ METHODS: We simulated 4 EID testing strategies for HIV-exposed infants in South Africa: no EID (diagnosis only after illness; hereafter, "no EID"), testing once (at birth alone or at 6 weeks of age alone; hereafter, "birth alone" and "6 weeks alone," respectively), and testing twice (at birth and 6 weeks of age; hereafter "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), the no EID strategy produced a life expectancy of 21.1 years (in the HIV-infected group) and 61.1 years (in the HIV-exposed group); lifetime cost averaged $1430/HIV-exposed infant. The birth and 6 weeks strategy maximized life expectancy (26.5 years in the HIV-infected group and 61.4 years in the HIV-exposed group), costing $1840/infant tested. The ICER of the 6 weeks alone strategy versus the no EID strategy was $1250/year of life saved (19% of South Africa's per capita gross domestic product); the ICER for the birth and 6 weeks strategy versus the 6 weeks alone strategy was $2900/year of life saved (45% of South Africa's per capita gross domestic product). Increasing the proportion of caregivers who receive test results and the linkage of HIV-positive infants to antiretroviral therapy with the 6 weeks alone strategy improved survival more than adding a second test. CONCLUSIONS:EID at birth and 6 weeks improves outcomes and is cost-effective, compared with EID at 6 weeks alone. If scale-up costs are comparable, programs should add birth testing after strengthening 6-week testing programs.
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