Estimating the cost of diagnosing HIV at birth in Lesotho
M Tchuenche1, M M Gill2, L Bollinger1
1Avenir Health, Project SOAR (Supporting Operational AIDS Research), Washington DC, United States of America.
Insights
Adding very early infant diagnosis (VEID) testing at birth for HIV in Lesotho can identify infected infants sooner. This strategy averts potential early infant deaths by enabling rapid antiretroviral therapy (ART) initiation.
Area of Science:
- Public Health
- Virology
- Health Economics
Background:
- Infants infected with HIV in utero face high mortality without timely antiretroviral therapy (ART).
- The World Health Organization recommends virologic diagnostic testing for infants at 4–6 weeks of age.
- Very early infant diagnosis (VEID) testing at birth offers potential for earlier detection and treatment of in utero HIV infections.
Purpose of the Study:
- To assess the costs associated with implementing VEID testing at birth in Lesotho.
- To evaluate the impact of VEID on identifying HIV-infected infants compared to standard 6-week testing.
- To determine the cost-effectiveness of VEID under various epidemic scenarios.
Main Methods:
- Retrospective cost data collection from eight health facilities and the National Reference Laboratory in Lesotho.
- Observational prospective study including birth testing and standard 6-week testing.
- Extrapolation of cost-per-infection data to the national level.
Main Results:
- The unit cost per VEID test in Lesotho was $40.50, with supplies and clinical labor as major cost drivers.
- In 2015, VEID identified 0.5% of infants as HIV-positive at birth, costing $8,060 per infection identified.
- Sensitivity analysis indicated costs ranging from $810 to $16,194 per infected child, depending on in utero infection rates.
Conclusions:
- Adding VEID birth testing to standard 6-week testing in Lesotho is a viable strategy for early HIV identification in infants.
- The cost-effectiveness of VEID is highest in settings with high HIV prevalence and low Prevention of Mother-to-Child Transmission (PMTCT) coverage.
- VEID has the potential to avert early infant deaths by enabling prompt ART initiation for HIV-positive newborns.
Background:
Infants with HIV infection, particularly those infected in utero, who do not receive antiretroviral therapy (ART) have high mortality in the first year of life. Virologic diagnostic testing is recommended by the World Health Organization between ages 4 and 6 weeks after birth. However, adding very early infant diagnosis (VEID) testing at birth has been suggested to enable earlier diagnosis and rapid treatment of in utero infection. We assessed the costs of adding VEID to the standard 6-week testing in Lesotho where coverage of PMTCT services is nearly universal.
Methods:
Retrospective cost data were collected at eight health-care facilities in three districts participating in an observational prospective study that included birth testing as well as at the National Reference Laboratory in Lesotho, to investigate the cost-per-infection identified. Extrapolating to the national level, it was possible to estimate the impact of VEID on the identification of HIV-infected infants.
Results:
The unit cost-per-VEID test in Lesotho in 2015 was $40.50. Major cost drivers were supplies/commodities (46%) and clinical labor (22%). In 2015, 66.3% of cohort study infants born at study facilities underwent VEID; one out of 199 infants had a positive HIV DNA PCR test at birth (0.5% potential in utero infection), yielding a cost of $8,060 per HIV-positive infant identified. Sensitivity analysis showed costs based on Lesotho costing data ranged from $810 to $16,194 per-infected child with varying in utero infection rates from 5% and 0.25%, respectively. With 11,157 HIV-exposed births nationally from pregnant women on PMTCT, 66.3% VEID coverage, and 0.5% in utero infection, 37 infants infected with HIV could have been identified at birth in 2015 and 8 early infant deaths potentially averted with immediate ART compared with waiting for 6-week testing.
Conclusion:
If Lesotho costing data from this pilot study were applied to different epidemic circumstances, the cost-per-infected child identified by adding VEID birth testing to standard 6-week testing was lowest when in utero infection rates were high (when HIV prevalence is high and PMTCT coverage is low).
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