XVIII International AIDS Conference


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Potential impact and cost-effectiveness of the 2009 “rapid advice” PMTCT guidelines - 15 resource-limited countries, 2010

Presented by Andrew Francis Auld (United States).

A.F. Auld, O. Bolu, T. Creek, M.L. Lindegren, E. Rivadeneira, H. Dale, N. Sangrugee, T. Ellerbrock

Centers for Disease Control and Prevention (CDC), Global AIDS Program, Atlanta, United States

Background: The 2009 World Health Organization (WHO) “Rapid Advice” guidelines on prevention of mother-to-child transmission (PMTCT) recommend starting antiretroviral therapy (ART) at earlier disease stages for HIV-infected pregnant women and one of two options for ART-ineligible women. Option “A”, includes maternal zidovudine and lamivudine (dual therapy) pre-natally, and daily infant nevirapine during breastfeeding. Option “B”, includes one of four maternal triple antiretroviral prophylaxis regimens during pregnancy and breastfeeding. Previous guidelines recommended dual therapy pre-natally and no breastfeeding prophylaxis for ART-ineligible women.
Methods: Using a deterministic model, we analyzed cost-effectiveness of implementing new guidelines under options “A” or “B” instead of previous guidelines for projected cohorts of HIV-infected pregnant women and exposed infants born in 12 African countries, Guyana, Haiti and Vietnam in 2010. PMTCT-effectiveness data were obtained from “Kesho Bora” and “BAN” randomized trials. PMTCT-coverage and costs were obtained from literature review. Outcome measures included infections averted and life-years gained (LYG) through averted infections. The analytic time horizon for infection risk was pregnancy through breastfeeding. LYG and costs of infant treatment were excluded. Option “A” or “B” was considered highly cost-effective if its incremental cost-effectiveness ratio (ICER) was < US$ 1,463 (the weighted average gross domestic product per capita for the 15 countries). A Monte-Carlo simulation for 10,000 trials constructed 95% confidence intervals (CI).

 Previous PMTCT Guidelines (2006) Estimate (95% CI)2009 “Rapid Advice” Guidelines - Option “A” Estimate (95% CI)2009 “Rapid Advice” Guidelines - Option “B” Estimate (95% CI)
Infections Averted70 thousand (29-104)149 thousand (116-187)135 thousand (94-165)
Life-Years Gained (3% Annual Discount)1.4 million (0.3-2.4)2.8 million (2.0-3.9)2.6 million (1.6-3.5)
Total CostsUS$ 63 million (54-76)US$ 234 million (210-266)US$ 364-692 million (309-735) depending on antiretrovirals used
[Impact of 2009 WHO 'Rapid Advice' PMTCT Guidelines]

The ICER of option “A” was US$ 119 (95% CI, 97-128). Option “B” was dominated (i.e. similarly effective but costlier than option “A”).
Conclusions: In 2010 in the 15 countries, implementing new PMTCT guidelines could prevent twice as many infections as previous guidelines. Option “A” is highly cost-effective.

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