Cost-effectiveness analysis of Option B+ for HIV prevention and treatment of mothers and children in Malawi.

BACKGROUND: The Ministry of Health in Malawi is implementing a pragmatic and innovative approach for the management of all HIV-infected pregnant women, termed Option B+, which consists of providing life-long antiretroviral treatment, regardless of their CD4 count or clinical stage. Our objective was to determine if Option B+ represents a cost-effective option. METHODS: A decision model simulates the disease progression of a cohort of HIV-infected pregnant women receiving prophylaxis and antiretroviral therapy, and estimates the number of paediatric infections averted and maternal life years gained over a ten-year time horizon. We assess the cost-effectiveness from the Ministry of Health perspective while taking into account the practical realities of implementing ART services in Malawi. RESULTS: If implemented as recommended by the World Health Organization, options A, B and B+ are equivalent in preventing new infant infections, yielding cost effectiveness ratios between US$37 and US$ 69 per disability adjusted life year averted in children. However, when the three options are compared to the current practice, the provision of antiretroviral therapy to all mothers (Option B+) not only prevents infant infections, but also improves the ten-year survival in mothers more than four-fold. This translates into saving more than 250,000 maternal life years, as compared to mothers receiving only Option A or B, with savings of 153,000 and 172,000 life years respectively. Option B+ also yields favourable incremental cost effectiveness ratios (ICER) of US$ 455 per life year gained over the current practice. CONCLUSION: In Malawi, Option B+ represents a favorable policy option from a cost-effectiveness perspective to prevent future infant infections, save mothers' lives and reduce orphanhood. Although Option B+ would require more financial resources initially, it would save societal resources in the long-term and represents a strategic option to simplify and integrate HIV services into maternal, newborn and child health programmes

Newborn survival in Uganda: a decade of change and future implications.

Each year in Uganda 141 000 children die before reaching their fifth birthday; 26% of these children die in their first month of life. In a setting of persistently high fertility rates, a crisis in human resources for health and a recent history of civil unrest, Uganda has prioritized Millennium Development Goals 4 and 5 for child and maternal survival. As part of a multi-country analysis we examined change for newborn survival over the past decade through mortality and health system coverage indicators as well as national and donor funding for health, and policy and programme change. Between 2000 and 2010 Uganda's neonatal mortality rate reduced by 2.2% per year, which is greater than the regional average rate of decline but slower than national reductions in maternal mortality and under-five mortality after the neonatal period. While existing population-based data are insufficient to measure national changes in coverage and quality of services, national attention for maternal and child health has been clear and authorized from the highest levels. Attention and policy change for newborn health is comparatively recent. This recognized gap has led to a specific focus on newborn health through a national Newborn Steering Committee, which has been given a mandate from the Ministry of Health to advise on newborn survival issues since 2006. This multi-disciplinary and inter-agency network of stakeholders has been able to preside over a number of important policy changes at the level of facility care, education and training, community-based service delivery through Village Health Teams and changes to essential drugs and commodities. The committee's comprehensive reach has enabled rapid policy change and increased attention to newborn survival in a relatively short space of time. Translating this favourable policy environment into district-level implementation and high quality services is now the priority

Costs and paediatric outcomes from preventing mother to child transmission programmatic interventions for 18 months of prophylaxis and treatment^* (US $ 2010).

*<p>Assumes 663,000 pregnant women, 66,500 HIV-infected pregnant women annually, and 90% (59,850) of those women reached by Option A, B and B+.</p>**<p>Assumes no needed CD4 to start ART under the Malawi Option B+ approach; however, in practice some HIV-infected pregnant women will have access to CD4 testing as part of staging and response to treatment</p>***<p>Background infections if no ARV interventions = 20,681</p

<b>Table 1.</b> ARV regimens for HIV prevention and treatment of mothers and children compared in the analysis - Current Practice 2010, WHO Option A, WHO Option B and Malawi's Option B+.

<p><b>Table 1.</b> ARV regimens for HIV prevention and treatment of mothers and children compared in the analysis - Current Practice 2010, WHO Option A, WHO Option B and Malawi's Option B+.</p

Input parameters and plausible ranges used for sensitivity analysis and relevant references for the Malawi analysis (US $ 2010).

<p>Input parameters and plausible ranges used for sensitivity analysis and relevant references for the Malawi analysis (US $ 2010).</p

Tornado diagram for the ICER of Option B+, base case is $455 per life year gained shown with the dotted line.

<p>Tornado diagram for the ICER of Option B+, base case is $455 per life year gained shown with the dotted line.</p

Cost effectiveness of various strategies for the prevention of new pediatric infections and the treatment of HIV-infected mothers in Malawi.

<p>Current practice represents our base case scenario or the status quo in 2010. The next set of scenarios highlight the cost effectiveness of incrementally expanding program implementation and service delivery coverage, and ranges from PMTCT only to the addition of integrated ART-ANC services for eligible pregnant women, both identified immediately and at a later time. Universal coverage implies the availability of HIV services for mother and children at any point of needing treatment. Option B+ offers ART to pregnant women regardless of CD4 count.</p

Results from sensitivity analyses on input parameters affecting outcomes in HIV-infected mothers; USperlifeyeargained(comparedtothecurrentpractice)andpaediatricoutcomes;US per life year gained (compared to the current practice) and paediatric outcomes; US per DALY averted.

<p>Results from sensitivity analyses on input parameters affecting outcomes in HIV-infected mothers; US$per life year gained (compared to the current practice) and paediatric outcomes; US$ per DALY averted.</p

Abbreviated decision tree summarizing the analytical approach, policy options and results.

<p>Abbreviated decision tree summarizing the analytical approach, policy options and results.</p