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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

Budget impact analysis.Antenatal and pediatric care costs are shown for the first five years after birth. We include the POC and laboratory base case strategies, as well as the low laboratory access scenario. The arrows indicate the time points at which the upfront higher costs of POC testing are recovered due to savings in pediatric care costs. The open arrow indicates that POC becomes cost-saving compared to “low-access” laboratory testing within six months of delivery; the closed arrow indicates that POC becomes cost-saving compared to the base-case laboratory testing strategy within 36 months after delivery. Costs over the first five years after birth are further detailed in S4 Table. Maternal costs were nearly equivalent for both strategies, and are not shown. The sharp inflection point in costs at 6 months after delivery represents the cessation of breastfeeding the associated costs for infant nevirapine for postnatal MTCT prophylaxis. Abbreviations: POC: point-of-care testing; ANC: antenatal.
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pone.0117751.g004: Budget impact analysis.Antenatal and pediatric care costs are shown for the first five years after birth. We include the POC and laboratory base case strategies, as well as the low laboratory access scenario. The arrows indicate the time points at which the upfront higher costs of POC testing are recovered due to savings in pediatric care costs. The open arrow indicates that POC becomes cost-saving compared to “low-access” laboratory testing within six months of delivery; the closed arrow indicates that POC becomes cost-saving compared to the base-case laboratory testing strategy within 36 months after delivery. Costs over the first five years after birth are further detailed in S4 Table. Maternal costs were nearly equivalent for both strategies, and are not shown. The sharp inflection point in costs at 6 months after delivery represents the cessation of breastfeeding the associated costs for infant nevirapine for postnatal MTCT prophylaxis. Abbreviations: POC: point-of-care testing; ANC: antenatal.

Mentions: In the base-case analysis, the higher upfront costs of POC were offset within 36 months after birth compared to laboratory, when both strategies reached costs of $490/mother-infant pair (Fig. 4, solid arrow). In the low laboratory access scenario, the upfront costs of POC were offset within 6 months after birth compared to laboratory (Fig. 4, open arrow). In both the base-case and low laboratory access scenarios, pediatric survival was slightly greater with POC than with laboratory at all time points (S4 Table).


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)

Budget impact analysis.Antenatal and pediatric care costs are shown for the first five years after birth. We include the POC and laboratory base case strategies, as well as the low laboratory access scenario. The arrows indicate the time points at which the upfront higher costs of POC testing are recovered due to savings in pediatric care costs. The open arrow indicates that POC becomes cost-saving compared to “low-access” laboratory testing within six months of delivery; the closed arrow indicates that POC becomes cost-saving compared to the base-case laboratory testing strategy within 36 months after delivery. Costs over the first five years after birth are further detailed in S4 Table. Maternal costs were nearly equivalent for both strategies, and are not shown. The sharp inflection point in costs at 6 months after delivery represents the cessation of breastfeeding the associated costs for infant nevirapine for postnatal MTCT prophylaxis. Abbreviations: POC: point-of-care testing; ANC: antenatal.
© Copyright Policy
Related In: Results  -  Collection

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

pone.0117751.g004: Budget impact analysis.Antenatal and pediatric care costs are shown for the first five years after birth. We include the POC and laboratory base case strategies, as well as the low laboratory access scenario. The arrows indicate the time points at which the upfront higher costs of POC testing are recovered due to savings in pediatric care costs. The open arrow indicates that POC becomes cost-saving compared to “low-access” laboratory testing within six months of delivery; the closed arrow indicates that POC becomes cost-saving compared to the base-case laboratory testing strategy within 36 months after delivery. Costs over the first five years after birth are further detailed in S4 Table. Maternal costs were nearly equivalent for both strategies, and are not shown. The sharp inflection point in costs at 6 months after delivery represents the cessation of breastfeeding the associated costs for infant nevirapine for postnatal MTCT prophylaxis. Abbreviations: POC: point-of-care testing; ANC: antenatal.
Mentions: In the base-case analysis, the higher upfront costs of POC were offset within 36 months after birth compared to laboratory, when both strategies reached costs of $490/mother-infant pair (Fig. 4, solid arrow). In the low laboratory access scenario, the upfront costs of POC were offset within 6 months after birth compared to laboratory (Fig. 4, open arrow). In both the base-case and low laboratory access scenarios, pediatric survival was slightly greater with POC than with laboratory at all time points (S4 Table).

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