Consolidated guidelines on HIV testing services, 2019: web annex F. Modelling the cost-effectiveness of maternal HIV retesting in high- and low-HIV burden settings (abstract)

Web Annex F CONSOLIDATED GUIDELINES ON HIV TESTING SERVICES 2019 Web Annex F. Modelling the cost–effectiveness of maternal HIV retesting in high- and low-HIV burden settings (abstract) ISBN 978-92-4-001178-6 (electronic version) Web Annex F Consolidated guidelines on HIV testing services, 2019. Web Annex F. Modelling the cost–effectiveness of maternal HIV retesting in high- and low-HIV burden settings (abstract)/ Julianne Meisner, Allen Roberts, Patricia Rodriguez, Morkor Newman Owiredu, Monisha Sharma, Bertha Gomez et al. ISBN 978-92-4-001178-6 (electronic version) This publication was originally published under WHO reference number WHO/UCN/HHS/19.45. © 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. Meisner J, Roberts A, Rodriguez P, Owiredu MN, Sharma M, Gomez B et al. Web Annex F. Modelling the cost– effectiveness of maternal HIV retesting 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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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. This publication forms part of the WHO guideline entitled Consolidated guidelines on HIV testing services, 2019. It is being made publicly available for transparency purposes and information, in accordance with the WHO handbook for guideline development, 2nd edition (2014). 1 Web Annex F Modelling the cost–effectiveness of maternal HIV retesting in high- and low-HIV burden settings (abstract) Julianne Meisner, Allen Roberts, Patricia Rodriguez, Morkor Newman Owiredu, Monisha Sharma Bertha Gomez, Maeve B. Mello; Alexey Bobrik, Arkadii Vodianyk, Andrew Storey, George Githuka, Thato Chidarikire, Ruanne Barnabas, Shiza Farid, Shaffiq Essajee, Muhammad S. Jamil, Rachel Baggaley, Cheryl Johnson, Alison L. Drake Background: HIV retesting during late pregnancy and breastfeeding can help detect new maternal infections and prevent mother-to-child HIV transmission (MTCT) but the optimal timing and cost–effectiveness of retesting is uncertain. Methods: We constructed Markov models to assess the health and economic impact of maternal HIV retesting on MTCT in four countries: Kenya and South Africa (high/intermediate HIV prevalence) and Colombia and Ukraine (low HIV prevalence). We evaluated five scenarios with varying retesting frequencies between late pregnancy through nine months postpartum. We compared strategies using incremental cost–effectiveness ratios (ICERs) with a cost–effectiveness threshold of 50% GDP. Findings: Maternal retesting once during late pregnancy with catch-up testing through six weeks postpartum was cost– effective in both Kenya (ICER=$241 per DALY averted) and South Africa (ICER=$572), and prevented 24% and 21% of infant HIV infections attributable to new maternal infections, respectively. Adding one or two additional retests during postpartum provided marginal benefits (2-4% higher infections averted compared to one retest). Adding 3 retests during the postpartum period provided higher benefits (5-8% higher infections averted) but ICERs greatly exceeded the cost– effectiveness threshold ($7,820 and $10,463 in Kenya and South Africa, respectively). In Colombia and Ukraine, all retesting strategies exceeded the cost–effectiveness threshold and prevented few infant infections (up to 33 and 5 infections, respectively). Interpretation: In high HIV burden settings, HIV retesting once during late pregnancy is the most cost–effective strategy for preventing infant HIV infections. Adding one or two more HIV tests postpartum marginally reduced MTCT, and was less costly than adding three retests. Retesting in Colombia and Ukraine was not cost–effective at any time point due to very low HIV prevalence and low breastfeeding probability among HIV positive mothers. 2 Web Annex F Table F1. Infant HIV infections and deaths averted and cost–effectiveness of maternal HIV retesting scenarios vs. base case scenario Retesting scenario Infant infections Total infections averted % max infections averted Infant deaths Total cost Incremental cost Total DALYs Incremental DALYs averted ICER ICER (one additional retest) KENYA No retesting 11,358 - - 60,749 $68,287,502 - 1,381,394 - - - Late ANC 9,988 1,370 24% 60,522 $70,150,578 $1,863,077 1,373,657 7,737 $241 - Late ANC + 9 mo 9,875 1,483 27% 60,503 $73,502,410 $3,351,832 1,373,019 638 Dom Dom Late ANC + 14 wk 9,782 1,576 29% 60,488 $73,504,891 $2,481 1,372,496 523 $2,889 $586 Late ANC + 6 mo 9,862 1,496 27% 60,501 $73,766,860 $261,969 1,372,946 -450 Dom Dom Late ANC + 6 mo + 9 mo 9,791 1,567 28% 60,490 $76,873,200 $3,106,340 1,372,547 399 Dom - Late ANC + every 3 mo 9,638 1,720 32% 60,464 $79,854,386 $2,981,186 1,371,684 863 $7,820 - SOUTH AFRICA No retesting 23,813 - - 40,560 $160,462,228 - 888,751 - - - Late ANC 22,283 1,530 21% 40,315 $165,327,727 $4,865,499 880,244 8,507 $572 - Late ANC + 9 mo 22,190 1,623 22% 40,300 $169,557,567 $4,229,840 879,729 515 Dom $1,008 Late ANC + 14 wk 22,111 1,702 23% 40,288 $170,123,643 $566,076 879,289 440 $5,022 $1,287 Late ANC + 6 mo 22,129 1,684 23% 40,291 $171,334,927 $1,211,285 879,388 -99 Dom Dom Late ANC + 6 mo + 9 mo 22,073 1,740 24% 40,282 $175,105,535 $3,770,608 879,080 308 Dom - Late ANC + every 3 mo 21,953 1,860 26% 40,262 $179,351,943 $4,246,407 878,407 673 $10,463 - COLOMBIA No retesting 145 - - 4,530 $5,223,684 - 89,819 - - - Late ANC 122 23 23% 4,525 $7,710,287 $2,486,603 89,662 157 $15,838 - Late ANC + 14 wk 116 29 30% 4,524 $9,752,100 $2,041,813 89,626 36 $56,717 $23,463 Late ANC + 9 mo 118 27 29% 4,524 $9,805,091 $52,991 89,635 -9 Dom Dom Late ANC + 6 mo 118 27 28% 4,524 $9,857,146 $52,055 89,640 -5 Dom Dom Late ANC + 6 mo + 9 mo 116 29 31% 4,523 $11,915,561 $2,058,415 89,623 17 Dom - Late ANC + every 3 mo 112 33 37% 4,523 $13,908,146 $1,992,585 89,595 28 $134,066 - UKRAINE No retesting 71 - - 3,101 $8,649,480 - 57,636 - - - Late ANC 67 4 31% 3,100 $10,129,331 $1,479,851 57,615 21 $70,469 - Late ANC + 14 wk 66 5 40% 3,100 $11,512,296 $1,382,966 57,610 5 $276,593 $110,108 Late ANC + 9 mo 66 5 37% 3,100 $11,540,744 $28,447 57,612 -2 Dom Dom Late ANC + 6 mo 67 4 36% 3,100 $11,565,259 $24,515 57,612 0 Dom Dom Late ANC + 6 mo + 9 mo 66 5 39% 3,100 $12,966,470 $1,401,212 57,611 1 Dom - Late ANC + every 3 mo 66 5 46% 3,100 $14,333,842 $1,367,372 57,608 3 $1,410,773 - aLate ANC is between 36-39 weeks of gestation. bTesting offered in late ANC, or at delivery if not performed at late ANC, or at 6 week MCH visit if not performed at delivery or late pregnancy. cApproximately every 3 months PP includes retesting at 6 weeks, 14 weeks, 6 months, and 9 months PP. dThe percent of maximum possible infections averted among women eligible for retesting was calculated as the number of infant infections averted by a specific retesting scenario divided by the total number of infant infections accrued under no retesting (scenario 1). eICER, incremental cost– effectiveness ratio, calculated as incremental costs (in 2017 US$) divided by DALYs averted compared with the next least-costly scenario with dominated and weakly dominated scenarios removed. ANC, antenatal care; PP, postpartum; DALY, disability-adjusted life-year; Dom, dominated (more costly and less effective than dominating scenario). *Indicates scenario is cost–effective compared to $500 per DALY threshold.