Ethiopian Review

Cost-effectiveness of routine rapid human immunodeficiency virus antibody testing before DNA-PCR testing for early diagnosis of infants in resource-limited settings.

Menzies NA, Homsy J, Chang Pitter JY, Pitter C, Mermin J, Downing R, Finkbeiner T, Obonyo J, Kekitiinwa A, Tappero J, Blandford JM. Pediatr Infect Dis J. 2009 28:819-25.

Infants born to HIV-infected women should receive HIV testing to allow early diagnosis and treatment. Recommendations for resource-limited settings stress laboratory-based virologic assays. While effective, these tests are logistically complex and expensive. This study explored the cost-effectiveness of incorporating initial screening with rapid HIV tests into the conventional testing algorithm to screen-out HIV-uninfected infants, thereby reducing the need for costly virologic testing. Data on HIV prevalence, rapid HIV tests sensitivity and specificity, and costs were collected from 820 HIV-exposed children (1.5-18 months) attending 2 postnatal screening programs in Uganda during July 2005 to December 2006. Cost-effectiveness models compared the conventional testing algorithm DNA polymerase chain reaction (DNA-PCR with Roche Amplicor v1.5) with a modified algorithm (initial rapid HIV tests to screen-out HIV-uninfected infants before DNA-PCR). The model estimated that the conventional algorithm would identify 94.3% (91.8%-94.7%) of HIV-infected infants, compared with 87.8% (79.4%-90.5%) for a modified algorithm using rapid HIV tests (HIV 1/2 Determine) and excluding the need for DNA-PCR for HIV antibody-negative infants. Costs per infant were $23.47 ($23.32-$23.76) for the conventional algorithm and between $22.75 ($21.89-$23.31) and $7.58 ($6.41-$10.75) for the modified algorithm, depending on infant age and symptoms. Compared with the conventional algorithm, costs per HIV-infected infant identified using the modified algorithm were higher in 1.5-to 3-month-old infants, but significantly lower in 3-month-old and older infants. Models replicating the whole infant testing program showed the modified algorithm would have marginally lower sensitivity, but would reduce total program costs by 27% to 40%, producing an incremental cost-effectiveness ratio of $1489 ($686-$6781) for the conventional versus modified algorithms. Screening infants with rapid HIV tests before DNA-PCR is cost-effective in infants 3 months old or older. Incorporating rapid HIV tests into early infant testing programs could improve cost-effectiveness and reduce program costs.

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Editors’ note: In the absence of antiretroviral prophylaxis, between 70 and 85% of infants born to mothers with HIV infection do not acquire HIV during pregnancy, labour, and delivery. However, all infants born to such mothers will have a positive HIV antibody test because their mother’s HIV antibodies cross the placenta before birth and persist in the baby’s blood up to 18 months of age. Because parents want to know whether their baby is infected and because antiretroviral treatment should be started in infants as soon as HIV infection is detected, it is not acceptable to wait until 18 months of age for a negative HIV antibody test to confirm that the baby has no antibodies of its own. Current policy in Uganda recommends testing of all HIV-exposed infants at 10 weeks of age, at their second immunization visit, by DNA-PCR which detects the virus itself, not antibodies. Although cost-effectiveness studies such as this one are context-specific with results varying by HIV prevalence, costs of supplies and personnel, equipment, etc., they are nonetheless of interest for programme planners in similar settings. The idea of using a rapid test to screen out infants that are likely not infected and then use the DNA-PCR test only on those that are rapid test-positive is partly motivated by the cost and complexity of DNA-PCR testing and partly by an appreciation of the visit burden imposed on parents by repeated testing visits should the first DNA-PCR be negative and the baby continues to breastfeed. Given that the algorithm studied here was cost-effective only in infants 3 months or older, there is not much to suggest that Uganda should change its current 10-week DNA-PCR testing policy. Using a rapid test to screen above that age in breastfeeding infants in order to decide whether a DNA-PCR should be done could be considered.

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Cost-effectiveness of newborn circumcision in reducing lifetime HIV risk among U.S. males.

Sansom SL, Prabhu VS, Hutchinson AB, An Q, Hall HI, Shrestha RK, Lasry A, Taylor AW. PLoS One. 2010;5:e8723.

HIV incidence was substantially lower among circumcised versus uncircumcised heterosexual African men in three clinical trials. Based on those findings, the authors modelled the potential effect of newborn male circumcision on a U.S. male’s lifetime risk of HIV, including associated costs and quality-adjusted life-years saved. Given published estimates of U.S. males’ lifetime HIV risk, they calculated the fraction of lifetime risk attributable to heterosexual behaviour from 2005-2006 HIV surveillance data. They assumed 60% efficacy of circumcision in reducing heterosexually-acquired HIV over a lifetime, and varied efficacy in sensitivity analyses. They calculated differences in lifetime HIV risk, expected HIV treatment costs and quality-adjusted life years (QALYs) among circumcised versus uncircumcised males. The main outcome measure was cost per HIV-related QALY saved. Circumcision reduced the lifetime HIV risk among all males by 15.7% in the base case analysis, ranging from 7.9% for white males to 20.9% for black males. Newborn circumcision was a cost-saving HIV prevention intervention for all, black, and Hispanic males. The net cost of newborn circumcision per QALY saved was $87,792 for white males. Results were most sensitive to the discount rate, and circumcision efficacy and cost. Newborn circumcision resulted in lower expected HIV-related treatment costs and a slight increase in QALYs. It reduced the 1.87% lifetime risk of HIV among all males by about 16%. The effect varied substantially by race and ethnicity. Racial and ethnic groups who could benefit the most from circumcision may have least access to it due to insurance coverage and state Medicaid policies, and these financial barriers should be addressed. More data on the long-term protective effect of circumcision on heterosexual males as well as on its efficacy in preventing HIV among men who have sex with men would be useful.

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Editors’ note: This cost-effectiveness analysis in the USA, which assessed the impact of infant male circumcision programmes on the lifetime HIV risk from heterosexual contact, found that African American and Hispanic males would benefit most from newborn circumcision. They have a higher lifetime risk of HIV, a higher risk of acquiring through heterosexual contact (6.2% for black males versus 0.94% for white males), and lower adult male circumcision prevalence. Although 88% of white males are circumcised, this figure falls to 73% among black males, and 42% among Hispanic males. However, these very populations are often least likely, on financial and insurance coverage grounds, be able to obtain newborn circumcision in the current US health care system should they decide to circumcise their male infants on health grounds. These include reduced risk of some sexually transmitted infections, infant urinary tract infections, penile cancer and cervical cancer in female partners. Cost-effectiveness analysis can inform decision-making when conditions for implementation are in place. In this case, the long road to health care reform in the USA has possibly been a major factor delaying policy change on infant male circumcision in the USA.

- EthiopianReview.com