Universal Repeat Screening for Human Immunodeficiency Virus in the Third Trimester of Pregnancy: A Cost-Effectiveness Analysis.

OBJECTIVE: To assess the cost effectiveness of universal repeat screening for human immunodeficiency virus (HIV) infection in the third trimester of pregnancy. METHODS: A decision-analytic model was constructed to compare two strategies: screening for HIV infection in the first trimester alone compared with the addition of repeat screening in the third trimester. Probabilities, costs, and utilities were derived from the literature and varied in sensitivity analyses. The assumed incidence of HIV infection in pregnancy was 0.0145% or 14.5 per 100,000. Outcomes included costs (in 2022 U.S. dollars), maternal and neonatal quality-adjusted life-years (QALYs), and cases of neonatal HIV infection. Our theoretical cohort contained 3.8 million pregnant individuals, the approximate number of births per year in the United States. The willingness-to-pay threshold was set at $100,000/QALY. We performed univariable and multivariable sensitivity analyses to determine inputs that most influenced the model. RESULTS: Universal third-trimester screening prevented 133 cases of neonatal HIV infection in this theoretical cohort. Universal third-trimester screening led to an increased cost of $17.54 million and 2,732 increased QALYs, with an incremental cost-effectiveness ratio of $6,418.56 per QALY, less than the willingness-to-pay threshold. In a univariate sensitivity analysis, third-trimester screening remained cost effective with variation of HIV incidence in pregnancy to as low as 0.0052%. CONCLUSION: In a theoretical U.S.-based cohort of pregnant individuals, universal repeat screening for HIV infection in the third trimester was found to be cost effective and to reduce vertical transmission of HIV. These results merit consideration of a broader HIV-screening program in the third trimester.

Electrophysiological ventricular substrate of stroke: a prospective cohort study in the Atherosclerosis Risk in Communities (ARIC) study.

OBJECTIVES: The goal of the study was to determine an association of cardiac ventricular substrate with thrombotic stroke (TS), cardioembolic stroke (ES) and intracerebral haemorrhage (ICH). DESIGN: Prospective cohort study. SETTING: The Atherosclerosis Risk in Communities (ARIC) study in 1987-1989 enrolled adults (45-64 years), selected as a probability sample from four US communities (Minneapolis, Minnesota; Washington, Maryland; Forsyth, North Carolina; Jackson, Mississippi). Visit 2 was in 1990-1992, visit 3 in 1993-1995, visit 4 in 1996-1998 and visit 5 in 2011-2013. PARTICIPANTS: ARIC participants with analysable ECGs and no history of stroke were included (n=14 479; age 54±6 y; 55% female; 24% black). Ventricular substrate was characterised by cardiac memory, spatial QRS-T angle (QRS-Ta), sum absolute QRST integral (SAIQRST), spatial ventricular gradient magnitude (SVGmag), premature ventricular contractions (PVCs) and tachycardia-dependent intermittent bundle branch block (TD-IBBB) on 12-lead ECG at visits 1-5. OUTCOME: Adjudicated TS included a first definite or probable thrombotic cerebral infarction, ES-a first definite or probable non-carotid cardioembolic brain infarction. Definite ICH was included if it was the only stroke event. RESULTS: Over a median 24.5 years follow-up, there were 899 TS, 400 ES and 120 ICH events. Cox proportional hazard risk models were adjusted for demographics, cardiovascular disease, risk factors, atrial fibrillation, atrial substrate and left ventricular hypertrophy. After adjustment, PVCs (HR 1.72; 95% CI 1.02 to 2.92), QRS-Ta (HR 1.15; 95% CI 1.03 to 1.28), SAIQRST (HR 1.20; 95% CI 1.07 to 1.34) and time-updated SVGmag (HR 1.19; 95% CI 1.08 to 1.32) associated with ES. Similarly, PVCs (HR 1.53; 95% CI 1.03 to 2.26), QRS-Ta (HR 1.08; 95% CI 1.01 to 1.16), SAIQRST (HR 1.07; 95% CI 1.01 to 1.14) and time-updated SVGmag (HR 1.11; 95% CI 1.04 to 1.19) associated with TS. TD-IBBB (HR 3.28; 95% CI 1.03 to 10.46) and time-updated SVGmag (HR 1.23; 95% CI 1.03 to 1.47) were associated with ICH. CONCLUSIONS: PVC burden (reflected by cardiac memory) is associated with ischaemic stroke. Transient cardiac memory (likely through TD-IBBB) precedes ICH.