World Health Organization’s (WHO) new recommendation for the extended use of
triple drug antiretroviral prophylaxis for mother and infant is highly
cost-effective compared to the current short-course two drug therapy for the
prevention of mother-to-child transmission (PMTCT) in Nigeria, Maunank Shah and
colleagues reported in an analysis published in the advance online April
edition of AIDS.
up the current 10% PMTCT service coverage to the existing antenatal coverage of
58% the WHO’s recommendations would reduce mother-to-child transmission to
12.8% per year, compared to 16.1% with the current minimum standard of care.
cases of infant HIV and 230,400 disability-adjusted life years (DALYs) each
year would be averted. (DALYs refers to the number of years of life saved in
the Nigerian context, assuming that HIV infection is prevented).
represents an incremental cost-effectiveness ratio (ICER) of US$113 for each
DALY averted. (Incremental cost-effectiveness ratio represents the difference
in cost between using the existing intervention and the new intervention). This
is highly cost-effective according to a WHO recommended willingness-to-pay
threshold, which classifies any intervention that costs less than 1 x GDP per
capita as highly cost-effective. (GDP per capita was US$1191 in Nigeria in
is an important public health strategy and priority. An estimated 4-12% of
pregnant women are HIV-infected. Without any intervention MTCT rates are
approximately 30-45%. An estimated 67,000 to 125,000 children are infected
through MTCT each year. In 2009 240,000 children were reported to be living
current minimum standard of care comprises single-dose nevirapine (the least
effective of ARV prevention strategies) or short-course combination ARV
(zidovudine + lamivudine), which while more effective does not provide any
benefit to the mother for her own health.
evidence led to WHO’s new recommendations for extended ART for mothers and and
extended prophylaxis for infants. This strategy could reduce transmission to
1-2% but is anticipated to be considerably more expensive than current
strategies in Nigeria.
light of Nigeria’s
plans to scale up PMTCT programmes at the national level, the authors wanted to
determine whether WHO’s recommendations are a cost-effective policy choice
compared to the current short-course ART strategy in reducing mother-to-child
analysis was done from a health system perspective with a target population of
HIV-infected pregnant women in Nigeria
and a target audience that included the Ministry of Health and public-sector
decision-analysis model compared two strategies for PMTCT programme coverage:
The WHO new recommendation, Option B: extended maternal triple ART (zidovudine
(AZT)/lamivudine (3TC)/efavirenz(EFV) starting at 14 weeks of pregnancy
continued throughout breastfeeding with infant antiretroviral prophylaxis, and
Minimum standard of care in Nigeria:
short-course ART (AZT/3TC) from the 34th week of the pregnancy to
one week after delivery with single-dose nevirapine for the infant and mother during
primary outcomes were expected costs, paediatric HIV cases and total DALYs with
each strategy. Incremental cost effectiveness ratios (ICERs) determined
cost-effectiveness; that is the cost in US dollars for DALYs averted and the
cost in US dollars for the number of HIV cases prevented when comparing the two
authors note that from a health system perspective WHO’s recommendation could potentially be
cost-saving assuming the lifetime health costs for an HIV-infected child
increased to more than US$17,000, or if MTCT rates were to exceed 20%.
costs if coverage were extended to current pregnancy rates using the WHO recommendation
or the minimum standard of care would be US$48 million a year, and $10.5
million a year, respectively. While considerable funding is received from
PEPFAR and the Global Fund for HIV/AIDS services, a 2010 audit showed US$5.8 million was spent on PMTCT services.
average health system cost for each pregnancy using the WHO recommendation and
the MSOC would be US$401 and US$293, respectively.
authors note maintaining coverage at the current level of 10% using the MSOC
would cost the Nigerian health system approximately US$93,000,000 a year
resulting in the most expensive and least cost-effective choice. Offering the
WHO recommendation at 100% coverage would cost the same.
study authors noted a number of limitations, including difficulties in estimating
lifetime treatment costs for an HIV-infected child, the lack of inclusion of
any health care costs averted as a result of maternal treatment, and an
assumption that uptake of voluntary counselling and testing, as well as PMTCT
interventions, would be high among Nigerian women.
say that their model can help guide scale-up plans by demonstrating the
potential cost-effectiveness of different levels of coverage, allowing informed
decision-making about how to allocate scarce resources.
authors note cost-effectiveness is dependent upon the lifetime costs of caring
for infants infected perinatally and the efficacy of ARV regimens and add
“Despite potential variability in these parameters sensitivity analysis
suggests an almost 100% chance that the WHO recommendation…is the preferred
[and most cost-effective] option for PMTCT.”