Consolidated guidelines on HIV testing services, 2019: web annex G. Modelling the cost-effectiveness of using HIV/syphilis dual tests in antenatal care in high and low HIV burden settings (abstract)

Web Annex G CONSOLIDATED GUIDELINES ON HIV TESTING SERVICES 2019 Web Annex G. Modelling the cost–effectiveness of using HIV/syphilis dual tests in antenatal care in high- and low-HIV burden settings (abstract) ISBN 978-92-4-001179-3 (electronic version) Web Annex G Consolidated guidelines on HIV testing services, 2019. Web Annex G. Modelling the cost–effectiveness of using HIV/syphilis dual tests in antenatal care in high- and low-HIV burden settings (abstract)/ Patricia Rodriguez, Allen Roberts, Julianne Meisner, Morkor Newman Owiredu, Bertha Gomez, Maeve de Mello et al. ISBN 978-92-4-001179-3 (electronic version) This publication was originally published under WHO reference number WHO/UCN/HHS/19.46. © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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Suggested citation. Rodriguez P, Roberts A, Meisner J, Owiredu MN, Gomez B, de Mello M et al. Web Annex G. Modelling the cost– effectiveness of using HIV/syphilis dual tests in antenatal care in high- and low-HIV burden settings (abstract). In: Consolidated guidelines on HIV testing services, 2019. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. 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Web Annex G 1 Modelling the cost–effectiveness of using HIV/syphilis dual tests in antenatal care in high- and low-HIV burden settings (abstract) Patricia Rodriguez, Allen Roberts Julianne Meisner, Morkor Newman Owiredu, Bertha Gomez, Maeve de Mello, Alexey Bobrik, Arkadii Vodianyk, Andrew Storey, George Githuka, Thato Chidarikire, Ruanne Barnabas, Monisha Sharma, Magdalena Barr-DiChiara, Muhammad S. Jamil, Rachel Baggaley, Cheryl Johnson, Melanie M. Taylor, Alison L. Drake Background: Dual HIV/syphilis testing has been proposed for prevention of mother-to-child-transmission (PMTCT) of HIV and congenital syphilis. The cost–effectiveness of implementing dual testing in antenatal care (ANC) in countries with varying HIV prevalence is unknown. Methods: We developed Markov decision-analytic models for HIV and syphilis to estimate the costs and infant health outcomes (infections, deaths, and disability-adjusted life years (DALYs)) of maternal testing strategies: testing at the first ANC visit with individual tests (base case), testing at the first ANC with a dual test. We modeled countries with high/intermediate (South Africa, Kenya) and low (Colombia, Ukraine) HIV prevalence. Strategies with an incremental cost–effectiveness ratio (ICER) of <$500 per DALY averted were considered cost–effective. Findings: Routine testing at the first ANC with a dual test was cost–saving, compared to testing with individual tests (ICER: Kenya=-$23, South Africa=-$316, Colombia=-$844, Ukraine=-$454). Routine retesting with individual tests was cost–effective in Kenya (ICER= $437) and Colombia (ICER= $2,685) (comparator: individual testing at first ANC). Interpretation: Incorporating dual HIV/syphilis testing in ANC can be cost–effective, or cost–saving, across countries with varying HIV prevalence and may help support the goal of dual elimination of MTCT of HIV and congenital syphilis. New WHO recommendation and implementation guidance: All pregnant women should be tested for HIV, syphilis and hepatitis B surface antigen (HBsAg)* at least once and as early as possible, ideally at the first antenatal care visit (syphilis: strong recommendation, moderate-quality evidence; HBsAg*: strong recommendation, low-quality evidence). Dual HIV/syphilis rapid diagnostic tests (RDTs) can be considered as the first test in HIV testing strategies and algorithms in ANC settings (https://www.who.int/publications-detail/dual-hiv- syphilis-rapid-diagnostic-test). *Particularly in settings with a ≥2% HBsAg seroprevalence in the general population. Table G1. Dual HIV/syphilis testing model scenarios Model scenarios 1st ANC Syphilis 1st ANC HIV Late ANC Syphilis Late ANC HIV Base case (independent tests) RPR/TPHA Rapid - - Dual Dual Dual - - ANC, antenatal care; RPR, rapid plasma regain; TPHA, Treponema palladium hemagglutination assay. Dual test is a single, point-of-care rapid test for HIV and syphilis. Independent tests include rapid HIV tests and laboratory-based syphilis tests (RPR, TPHA to confirm reactive results). Late ANC is 36 to 39 weeks gestation. Web Annex G 2 Table G2. Health impact and cost–effectiveness of maternal HIV and syphilis testing scenarios. Testing scenarioa,b Total costs Total HIV infections Total syphilis infections Total DALYs Incremental costs Increm- ental DALYs averted ICER Com- parator KENYA Base: Individual tests – 1st ANC only $73,720,217 11,344 18,652 1,009,460 - - - - Dual test – 1st ANC only $73,493,646 11,346 15,676 999,689 -$226,571 9,771 $-23** Base SOUTH AFRICA Base: Individual tests – 1st ANC only $168,938,857 23,788 13,482 730,809 - - - - Dual test – 1st ANC only $164,743,010 23,795 9,347 717,523 -$4,195,847 13,286 $-316** Base COLOMBIA Base: Individual tests – 1st ANC only $6,275,872 145 1,281 73,248 - - - - Dual test – 1st ANC only $5,214,791 145 878 71,991 -$1,061,081 1,258 $-844** Base UKRAINE Base: Individual tests – 1st ANC only $8,866,150 71 2,333 54,817 - - - - Dual test – 1st ANC only $7,966,929 71 1,694 52,837 -$899,222 1,980 $-454** Base aDALYs averted and incremental costs are compared against the base case scenario. Individual tests are HIV rapid tests and RPR tests for syphilis; TPHA used for confirmatory syphilis testing for reactive RPR results. Reactive rapid HIV tests and dual HIV tests confirmed with an additional HIV rapid test. bICER, incremental cost–effectiveness ratio, in 2017 US$ per DALY averted; ANC, antenatal care; RPR, rapid plasma regain; TPHA, Treponema palladium hemagglutination assay; MCH, maternal and child health; DALY, disability-adjusted life-year. *Indicates scenario is cost–effective compared to $500 per DALY threshold. * Indicates scenario is cost–saving. Web Annex G