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Point-of-care CD4 testing to inform selection of antiretroviral medications in south african antenatal clinics: a cost-effectiveness analysis.

Ciaranello AL, Myer L, Kelly K, Christensen S, Daskilewicz K, Doherty K, Bekker LG, Hou T, Wood R, Francke JA, Wools-Kaloustian K, Freedberg KA, Walensky RP - PLoS ONE (2015)

Bottom Line: Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/life-year saved).POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant).Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs.

View Article: PubMed Central - PubMed

Affiliation: Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.

ABSTRACT

Background: Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays.

Methods: We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96%, result-return rate: 87%, cost: $14) and POC (test rate: 99%, result-return rate: 95%, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO "Option A"): antenatal zidovudine (CD4 ≤350/μL) or ART (CD4>350/μL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/life-year saved).

Results: In the base case, laboratory led to projected MTCT risks of 5.7%, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs.

Conclusions: In antenatal clinics implementing Option A, the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.

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Related in: MedlinePlus

Multivariate sensitivity analyses: Cost-effectiveness of POC CD4 testing compared to laboratory testing.The cost-effectiveness of POC CD4 testing compared to laboratory testing is shown for key combinations of POC CD4 assay cost, POC assay sensitivity, and POC CD4 test and result return rates, defined as the product of (proportion of HIV-identified women undergoing CD4 testing) * (proportion of CD4-tested women receiving CD4 results). Abbreviations: POC: point-of-care testing.
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pone.0117751.g003: Multivariate sensitivity analyses: Cost-effectiveness of POC CD4 testing compared to laboratory testing.The cost-effectiveness of POC CD4 testing compared to laboratory testing is shown for key combinations of POC CD4 assay cost, POC assay sensitivity, and POC CD4 test and result return rates, defined as the product of (proportion of HIV-identified women undergoing CD4 testing) * (proportion of CD4-tested women receiving CD4 results). Abbreviations: POC: point-of-care testing.

Mentions: When POC sensitivity, POC testing and POC result-return were high, POC was cost-saving at all POC assay costs from $13–52 (Fig. 3, upper right corners). Conversely, at very low POC sensitivity, testing, and result-return rates, POC became more expensive and less effective than laboratory (Fig. 3, lower left corners). As POC assay cost increased, fewer combinations of sensitivity, testing rates, and result-return rates allowed POC to be cost-saving; however, POC was cost-effective or very cost-effective in many of these scenarios (Fig. 3, band from upper left to lower right corners).


Point-of-care CD4 testing to inform selection of antiretroviral medications in south african antenatal clinics: a cost-effectiveness analysis.

Ciaranello AL, Myer L, Kelly K, Christensen S, Daskilewicz K, Doherty K, Bekker LG, Hou T, Wood R, Francke JA, Wools-Kaloustian K, Freedberg KA, Walensky RP - PLoS ONE (2015)

Multivariate sensitivity analyses: Cost-effectiveness of POC CD4 testing compared to laboratory testing.The cost-effectiveness of POC CD4 testing compared to laboratory testing is shown for key combinations of POC CD4 assay cost, POC assay sensitivity, and POC CD4 test and result return rates, defined as the product of (proportion of HIV-identified women undergoing CD4 testing) * (proportion of CD4-tested women receiving CD4 results). Abbreviations: POC: point-of-care testing.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4355621&req=5

pone.0117751.g003: Multivariate sensitivity analyses: Cost-effectiveness of POC CD4 testing compared to laboratory testing.The cost-effectiveness of POC CD4 testing compared to laboratory testing is shown for key combinations of POC CD4 assay cost, POC assay sensitivity, and POC CD4 test and result return rates, defined as the product of (proportion of HIV-identified women undergoing CD4 testing) * (proportion of CD4-tested women receiving CD4 results). Abbreviations: POC: point-of-care testing.
Mentions: When POC sensitivity, POC testing and POC result-return were high, POC was cost-saving at all POC assay costs from $13–52 (Fig. 3, upper right corners). Conversely, at very low POC sensitivity, testing, and result-return rates, POC became more expensive and less effective than laboratory (Fig. 3, lower left corners). As POC assay cost increased, fewer combinations of sensitivity, testing rates, and result-return rates allowed POC to be cost-saving; however, POC was cost-effective or very cost-effective in many of these scenarios (Fig. 3, band from upper left to lower right corners).

Bottom Line: Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/life-year saved).POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant).Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs.

View Article: PubMed Central - PubMed

Affiliation: Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.

ABSTRACT

Background: Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays.

Methods: We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96%, result-return rate: 87%, cost: $14) and POC (test rate: 99%, result-return rate: 95%, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO "Option A"): antenatal zidovudine (CD4 ≤350/μL) or ART (CD4>350/μL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/life-year saved).

Results: In the base case, laboratory led to projected MTCT risks of 5.7%, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs.

Conclusions: In antenatal clinics implementing Option A, the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.

Show MeSH
Related in: MedlinePlus