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PLoS One. 2015 Mar 10;10(3):e0117751. doi: 10.1371/journal.pone.0117751. eCollection 2015.

Point-of-care CD4 testing to inform selection of antiretroviral medications in south african antenatal clinics: a cost-effectiveness analysis.

Author information

1
Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
2
School of Public Health and Family Medicine, Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa.
3
General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
4
Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
5
General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
6
Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Illinois, United States of America.
7
Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America; Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America.
8
Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America.

Abstract

BACKGROUND:

Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays.

METHODS:

We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96%, result-return rate: 87%, cost: $14) and POC (test rate: 99%, result-return rate: 95%, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO "Option A"): antenatal zidovudine (CD4 ≤350/μL) or ART (CD4>350/μL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/life-year saved).

RESULTS:

In the base case, laboratory led to projected MTCT risks of 5.7%, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs.

CONCLUSIONS:

In antenatal clinics implementing Option A, the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.

PMID:
25756498
PMCID:
PMC4355621
DOI:
10.1371/journal.pone.0117751
[Indexed for MEDLINE]
Free PMC Article

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