Health care costs associated with clinic visits for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania.

ABSTRACT: Early and appropriate antenatal care (ANC) is key for the effectiveness of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). We evaluated the importance of ANC visits and related service costs for women receiving option B+ to prevent mother-to-child transmission (MTCT) of HIV in Tanzania.A cost analysis from a health care sector perspective was conducted using routine data of 2224 pregnant women newly diagnosed with HIV who gave birth between August 2014 and May 2016 in Dar es Salaam, Tanzania. We evaluated risk of infant HIV infection at 12 weeks postnatally in relation to ANC visits (<4 vs ≥4 visits). Costs for service utilisation were estimated through empirical observations and the World Health Organisation Global Price Reporting Mechanism.Mean gestational age at first ANC visit was 22 (±7) weeks. The average number of ANC/prevention of MTCT visits among the 2224 pregnant women in our sample was 3.6 (95% confidence interval [CI] 3.6-3.7), and 57.3% made ≥4 visits. At 12 weeks postnatally, 2.7% (95% CI 2.2-3.6) of HIV exposed infants had been infected. The risk of MTCT decreased with the number of ANC visits: 4.8% (95% CI 3.6-6.4) if the mother had <4 visits, and 1.0% (95% CI 0.5-1.7) at ≥4. The adjusted MTCT rates decreased by 51% (odds ratio 0.49, 95% CI 0.31-0.77) for each additional ANC visit made. The potential cost-saving was 2.2 US$ per woman at ≥4 visits (84.8 US$) compared to <4 visits (87.0 US$), mainly due to less defaulter tracing.Most pregnant women living with HIV in Dar es Salaam initiated ANC late and >40% failed to adhere to the recommended minimum of 4 visits. Improved ANC attendance would likely lead to fewer HIV-infected infants and reduce both short and long-term health care costs due to less spending on defaulter tracing and future treatment costs for the children.

Patient costs for prevention of mother-to-child HIV transmission and antiretroviral therapy services in public health facilities in Zimbabwe.

Zimbabwe has made large strides in addressing HIV. To ensure a continued robust response, a clear understanding of costs associated with its HIV program is critical. We conducted a cross-sectional evaluation in 2017 to estimate the annual average patient cost for accessing Prevention of Mother-To-Child Transmission (PMTCT) services (through antenatal care) and Antiretroviral Treatment (ART) services in Zimbabwe. Twenty sites representing different types of public health facilities in Zimbabwe were included. Data on patient costs were collected through in-person interviews with 414 ART and 424 PMTCT adult patients and through telephone interviews with 38 ART and 47 PMTCT adult patients who had missed their last appointment. The mean and median annual patient costs were examined overall and by service type for all participants and for those who paid any cost. Potential patient costs related to time lost were calculated by multiplying the total time to access services (travel time, waiting time, and clinic visit duration) by potential earnings (US$75 per month assuming 8 hours per day and 5 days per week). Mean annual patient costs for accessing services for the participants was US$20.00 [standard deviation (SD) = US$80.42, median = US$6.00, range = US$0.00-US$12,18.00] for PMTCT and US$18.73 (SD = US$58.54, median = US$8.00, range = US$0.00-US$ 908.00) for ART patients. The mean annual direct medical costs for PMTCT and ART were US$9.78 (SD = US$78.58, median = US$0.00, range = US$0.00-US$ 90) and US$7.49 (SD = US$60.00, median = US$0.00) while mean annual direct non-medical cost for US$10.23 (SD = US$17.35, median = US$4.00) and US$11.23 (SD = US$25.22, median = US$6.00, range = US$0.00-US$ 360.00). The PMTCT and ART costs per visit based on time lost were US$3.53 (US$1.13 to US$8.69) and US$3.43 (US$1.14 to US$8.53), respectively. The mean annual patient costs per person for PMTCT and ART in this evaluation will impact household income since PMTCT and ART services in Zimbabwe are supposed to be free.

How do patients prefer specialized clinical pharmacy service to other prevention of mother-to-child transmission of human immunodeficiency virus services? An evaluation of their willingness to pay and willingness to accept choices and ratios.

WHAT IS KNOWN AND OBJECTIVE: Donor agencies provide most of the funds for HIV services in developing countries. Due to the global economic downturn, there has been a reduction in funding for HIV-related services in Nigeria. This study compared the willingness to pay (WTP)-willingness to accept (WTA) ratios for prevention of mother-to-child transmission (PMTCT) services to specialized clinical pharmacy services among patients of two Nigerian hospitals. METHODS: This was a cross-sectional survey using contingent valuation method at Ahmadu Bello University Teaching Hospital (ABUTH) and University of Nigeria Teaching Hospital (UNTH). WTP and WTA were elicited using an interviewer-administered questionnaire and a payment card. The responses to the WTP and WTA questions were reported as frequencies and percentages, while the amounts were determined as mean. All costs were obtained in Nigerian Naira (N360 = $1). RESULTS AND DISCUSSION: Of the 219 mothers who participated in the study, 172 (78.5%) had no health insurance. Primary prevention of HIV (PPV) had the highest "yes" WTP response of 152 (69.4%) and the highest mean WTP amount of N6067.20. It also had the least "no" WTA response of 162 (74.0%) and the least WTA amount of N232.09. Specialized clinical pharmacy service (SCPS) had the highest WTA/WTP ratio of 4.0826 in ABUTH and 9.3750 at UNTH. Its income effect was -3.0826. A 1% increase in income led to 0.0550 (95% CI: -0.3068 to 0.1968) decreased odds to pay for PPV. WHAT IS NEW AND CONCLUSION: Most patients assessed in this study were willing to pay for PPV than other services. Majority of them were also willing to forgo PMTCT Drugs Only. SCPS had the highest value for the patients, but they did not want to pay a high amount for it. Employment status, health insurance status, educational level and age were predictors of patients' WTP and WTA.

Cost-effectiveness of dual maternal HIV and syphilis testing strategies in high and low HIV prevalence countries: a modelling study.

BACKGROUND: Dual HIV and syphilis testing might help to prevent mother-to-child transmission (MTCT) of HIV and syphilis through increased case detection and treatment. We aimed to model and assess the cost-effectiveness of dual testing during antenatal care in four countries with varying HIV and syphilis prevalence. METHODS: In this modelling study, we developed Markov models of HIV and syphilis in pregnant women to estimate costs and infant health outcomes of maternal testing at the first antenatal care visit with individual HIV and syphilis tests (base case) and at the first antenatal care visit with a dual rapid diagnostic test (scenario one). We additionally evaluated retesting during late antenatal care and at delivery with either individual tests (scenario two) or a dual rapid diagnosis test (scenario three). We modelled four countries: South Africa, Kenya, Colombia, and Ukraine. Strategies with an incremental cost-effectiveness ratio (ICER) less than the country-specific cost-effectiveness threshold (US$500 in Kenya, $750 in South Africa, $3000 in Colombia, and $1000 in Ukraine) per disability-adjusted life-year averted were considered cost-effective. FINDINGS: Routinely offering testing at the first antenatal care visit with a dual rapid diagnosis test was cost-saving compared with the base case in all four countries (ICER: -$26 in Kenya,-$559 in South Africa, -$844 in Colombia, and -$454 in Ukraine). Retesting during late antenatal care with a dual rapid diagnostic test (scenario three) was cost-effective compared with scenario one in all four countries (ICER: $270 in Kenya, $260 in South Africa, $2207 in Colombia, and $205 in Ukraine). INTERPRETATION: Incorporating dual rapid diagnostic tests in antenatal care can be cost-saving across countries with varying HIV prevalence. Countries should consider incorporating dual HIV and syphilis rapid diagnostic tests as the first test in antenatal care to support efforts to eliminate MTCT of HIV and syphilis. FUNDING: WHO, US Agency for International Development, and the Bill & Melinda Gates Foundation.

Analysis of cost burden of obstetric care among human immune-deficiency virus (HIV) positive women in Enugu metropolis, South-East Nigeria.

The cost of obstetric care could hinder the capacity of human immune-deficiency virus (HIV) positive women to receive adequate care during pregnancy and delivery. This study was aimed at determining the relationship between antenatal/delivery care cost and delivery place choice among HIV positive women in Enugu metropolis. This was a cross-sectional study of 232 post-partum HIV-positive women who came for 6-weeks post-natal visit. Data were analysed using SPSS version 20. The ethical clearance number obtained at UNTH on 18/11/2015 was NHREC/05/01/2008BFWA00002458-1RB00002323. The average obstetric care cost among the respondents was N55,405.67 (US$346.28). The delivery cost (p-value-0.043) had positive relationship with delivery place choice. The women's proportion delivered by skilled birth attendants (SBA) was 93.1%. In conclusion, obstetric care cost among HIV positive women in Enugu was high. The high obstetric care cost influenced the delivery place of one-third of them. The choice of ill-equipped health facilities may result in higher risk of HIV transmission.IMPACT STATEMENTWhat is already known on this subject? The high HIV/AIDs burden in Nigeria could be attributed to poverty, ignorance, corruption and poor implementation of policies targeted at halting the spread of the infection. The cost of obstetric care could hinder the capacity of HIV positive women to receive adequate care during pregnancy and delivery.What do the results of this study add? The cost of antenatal care (p-value = .02) and delivery (p-value = .001) had a significant positive relationship with the choice of place of delivery by the respondents. The proportion of the women delivered by SBA was 93.1%. Approximately 31.9% of the women delivered at the health facilities different from where they had antenatal care.What are the implications of these findings for clinical practice and/or further research? This implies that the obstetric care cost among HIV positive women in Enugu metropolis was catastrophic. Though 93.1% of the respondents were delivered by SBA, the high cost of obstetric care influenced the delivery of one-third of them at centres different from where they had antenatal care. This may lead to women delivering in poorly equipped health facilities, which, in turn, may result in a higher risk of mother-to-child HIV transmission.

Costs and Cost Drivers of Providing Option B+ Services to Mother-Baby Pairs for PMTCT of HIV in Health Centre IV Facilities in Jinja District, Uganda.

BACKGROUND: In 2013, the World Health Organization (WHO) revised the 2012 guidelines on use of antiretroviral drugs (ARVs) for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). The new guidelines recommended lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and breastfeeding women irrespective of CD4 count or clinical stage (also referred to as Option B+). Uganda started implementing Option B+ in 2012 basing on the 2012 WHO guidelines. Despite the impressive benefits of the Option B+ strategy, implementation challenges, including cost burden and mother-baby pairs lost to follow-up, threatened its overall effectiveness. The researchers were unable to identify any studies conducted to assess costs and cost drivers associated with provision of Option B+ services to mother-baby pairs in HIV care in Uganda. Therefore, this study determined costs and cost drivers of providing Option B+ services to mother-baby pairs over a two-year period (2014-2015) in selected health facilities in Jinja district, Uganda. METHODS: The estimated costs of providing Option B+ to mother-baby pairs derived from the provider perspective were evaluated at four health centres (HC) in Jinja district. A retrospective, ingredient-based costing approach was used to collect data for 2014 as base year using a standardized cost data capture tool. All costs were valued in United States dollars (USD) using the 2014 midyear exchange rate. Costs incurred in the second year (2015) were obtained by inflating the 2014 costs by the ratio of 2015 and 2014 USA Gross Domestic Product (GDP) implicit price deflator. RESULTS: The average total cost of Option B+ services per HC was 66,512.7 (range: 32,168.2-102,831.1) USD over the 2-year period. The average unit cost of Option B+ services per mother-baby pair was USD 441.9 (range: 422.5-502.6). ART for mothers was the biggest driver of total mean costs (percent contribution: 62.6%; range: 56.0%-65.5%) followed by facility personnel (percent contribution: 8.2%; range: 7.7%-11.6%), and facility-level monitoring and quality improvement (percent contribution: 6.0%; range: 3.2%-12.3%). Conclusions and Recommendations. ART for mothers was the major cost driver. Efforts to lower the cost of ART for PMTCT would make delivery of Option B+ affordable and sustainable.

Costs and economies of scale in the accelerated program for prevention of mother-to-child transmission of HIV in Zimbabwe.

BACKGROUND: Despite a growing body of literature on HIV service costs in sub-Saharan Africa, only a few studies have estimated the facility-level cost of prevention of Mother-to-Child Transmission (PMTCT) services, and even fewer provide insights into the variation of PMTCT costs across facilities. In this study, we present the first empirical costs estimation of the accelerated program for the prevention of mother-to-child transmission of HIV in Zimbabwe and investigate the determinants of heterogeneity of the facility-level average cost per service. To understand such variation, we explored the association between average costs per service and supply-and demand-side characteristics, and quality of services. One aspect of the supply-side we explore carefully is the scale of production-which we define as the annual number of women tested or the yearly number of HIV-positive women on prophylaxis. METHODS: We collected rich data on the costs and PMTCT services provided by 157 health facilities out of 699 catchment areas in five provinces in Zimbabwe for 2013. In each health facility, we measured total costs and the number of women covered with PMTCT services and estimated the average cost per woman tested and the average cost per woman on either ARV prophylaxis or ART. We refer to these facility-level average costs per service as unitary costs. We also collected information on potential determinants of the variation of unitary costs. On the supply-side, we gathered data on the scale of production, staff composition and on the types of antenatal and family planning services provided. On the demand side, we measured the total population at the catchment area and surveyed eligible pairs of mothers and infants about previous use of HIV testing and prenatal care, and on the HIV status of both mothers and infants. We explored the determinants of unitary cost variation using a two-stage linear regression strategy. RESULTS: The average annual total cost of the PMTCT program per facility was US$16,821 (median US$8,920). The average cost per pregnant woman tested was US$80 (median US$47), and the average cost per HIV-positive pregnant woman initiated on ARV prophylaxis or treatment was US$786 annually (median US$420). We found substantial heterogeneity of unitary costs across facilities regardless of facility type. The scale of production was a strong predictor of unitary costs variation across facilities, with a negative and statistically significant correlation between the two variables (p<0.01). CONCLUSIONS: These findings are the first empirical estimations of PMTCT costs in Zimbabwe. Unitary costs were found to be heterogeneous across health facilities, with evidence consistent with economies of scale.

Congenital Chagas Disease in the United States: The Effect of Commercially Priced Benznidazole on Costs and Benefits of Maternal Screening.

Chagas disease, caused by Trypanosoma cruzi, is transmitted by insect vectors, and through transfusions, transplants, insect feces in food, and mother to child during gestation. An estimated 30% of infected persons will develop lifelong, potentially fatal cardiac or digestive complications. Treatment of infants with benznidazole is highly efficacious in eliminating infection. This work evaluates the costs of maternal screening and infant testing and treatment for Chagas disease in the United States, including the cost of commercially available benznidazole. We compare costs of testing and treatment for mothers and infants with the lifetime societal costs without testing and consequent morbidity and mortality due to lack of treatment or late treatment. We constructed a decision-analytic model, using one tree that shows the combined costs for every possible mother-child pairing. Savings per birth in a targeted screening program are $1,314, and with universal screening, $105 per birth. At current screening costs, universal screening results in $420 million in lifetime savings per birth-year cohort. We found that a congenital Chagas screening program in the United States is cost saving for all rates of congenital transmission greater than 0.001% and all levels of maternal prevalence greater than 0.06% compared with no screening program.

Cost-effectiveness analysis of antiviral treatment for pregnant women with high viral load to prevent hepatitis B virus vertical transmission.

INTRODUCTION: Vertical transmission of the hepatitis B virus (HBV) is higher in infants born to pregnant women with a higher HBV DNA viral load even if the infants complete both active and passive vaccination. Although antiviral treatment is recommended for pregnant women during the antenatal period to reduce the rate of vertical transmission, most of them decline treatment. METHODS: A decision tree was made to evaluate the costs and benefits involved when pregnant women either agreed or declined to take antiviral treatment during the antenatal period. The cost-effectiveness price was arrived at by multiplying the reduced vertical transmission rate with expenses of future medical care associated with vertical transmission. RESULTS: From an individual mother's perspective, it was not cost-effective to receive antenatal antiviral treatment given the observed medication price and transmission rate in Singapore. However, the health system asserts that the current price of antiviral treatment is already far below the cost-effectiveness level, even without the Ministry of Health subsidies. Additionally, the awareness and perception of pregnant women also impacted treatment decisions. CONCLUSION: By analysing the decision-making process, our result explained the current low uptake rates of antenatal antiviral treatment for HBV among pregnant women. We also concluded that from the health system's perspective, it was worth providing subsidies for perinatal antiviral treatment to prevent huge expenses generated in the future by chronic HBV complications.

An approach for evaluating early and long term mother-to-child transmission of HIV (MTCT) in low and middle income countries: a South African experience.

BACKGROUND: Eliminating mother-to-child transmission of HIV is a global public health target. Robust, feasible methodologies to measure population level impact of programmes to prevent mother-to-child transmission of HIV (PMTCT) are needed in high HIV prevalence settings. We present a summary of the protocol of the South African PMTCT Evaluation (SAPMTCTE) with its revision over three repeated rounds of the survey, 2010-2014. METHODS: Three cross sectional surveys (2010, 2011-2012 and 2012-2013) were conducted in 580 primary health care immunisation service points randomly selected after stratified multistage probability proportional to size sampling. All infants aged 4-8 weeks receiving their six-week immunisation at a sampled facility on the day of the visit were eligible to participate. Trained research nurses conducted interviews and took infant dried blood spot (iDBS) samples for HIV enzyme immunoassay (EIA) and total nucleic acid polymerase chain reaction (PCR) testing. Interviews were conducted using mobile phones and iDBS were sent to the National Health Laboratory for testing. All findings were adjusted for study design, non-response, and weighted for number of South African live-birth in each study round. In 2012 a national closed cohort of these 4 to 8-week old infants testing EIA positive (HIV Exposed Infants) from the 2012-2013 cross-sectional survey was established to estimate longer-term PMTCT impact to 18 months. Follow-up analyses were to estimate weighted cumulative MTCT until 18 months, postnatal MTCT from 6 weeks until 18 months and a combined outcome of MTCT-or-death, using a competing risks model, with death as a competing risk. HIV-free survival was defined as a child surviving and HIV-negative up to 18 months or last visit seen. A weighted cumulative incidence analysis was conducted, adjusting for survey design effects. DISCUSSION: In the absence of robust high-quality routine medical recording systems, in the context of a generalised HIV epidemic, national surveys can be used to monitor PMTCT effectiveness; however, monitoring long-term outcomes nationally is difficult due to poor retention in care.

[Economic evaluation on strategy for preventing mother-to-child transmission of hepatitis B in Zhejiang Province].

Objective: To evaluate the cost-benefit and cost-effectiveness of current strategy for preventing mother-to-child transmission (PMTCT) of hepatitis B virus. Methods: A decision tree model with the Markov process was developed and simulated over the lifetime of a birth cohort in Zhejiang Province in 2016. The current PMTCT strategy was compared with universal vaccination and non-vaccination. Costs were assessed from social perspective. Benefits were the savings from reduced costs associated with disease and effectiveness were measured by quality-adjusted of life-years (QALY) gained. The net present value (NPV), cost-benefit ratio (BCR) and incremental cost-effectiveness ratio (ICER) were calculated. Univariate and Probabilistic Sensitivity Analyses (PSA) were performed to assess parameter uncertainties. The parameters of costs and utilities value of hepatitis B-related disease came from the results of the field survey, which were obtained by face-to-face questionnaire survey combined with inpatient medical records, including eight county and municipal hospitals in Jinhua, Jiaxing and Taizhou. A total of 626 outpatients and 523 inpatient patients were investigated. The annual total costs of infection was calculated by combining the costs of outpatient and inpatient. Results: The PMTCT strategy showed a net-gain as 38 323.78 CNY per person, with BCR as 21.10, which was higher than 36 357.80 CNY per person and 13.58 respectively of universal vaccination. Compared with universal vaccination, the PMTCT strategy would save 2 787.07 CNY per additional QALY gained for every person, indicating that PMTCT would be cost-saving. The most important parameters that could affect BCR and ICER were the vaccine coverage rate and costs of hepatitis B related diseases respectively. The PSA showed the PMTCT strategy was preferable as it would gain more QALY and save costs. Conclusions: The PMTCT strategy appeared as highly cost-beneficial and highly cost-effective. High vaccination rate was a key factor of high economic value.

Cost-effectiveness of option B+ in prevention of mother-to-child transmission of HIV in Yunnan Province, China.

BACKGROUND: Although Option B+ may be more costly than Options B, it may provide additional health benefits that are currently unclear in Yunnan province. We created deterministic models to estimate the cost-effectiveness of Option B+. METHODS: Data were used in two deterministic models simulating a cohort of 2000 HIV+ pregnant women. A decision tree model simulated the number of averted infants infections and QALY acquired for infants in the PMTCT period for Options B and B+. The minimum cost was calculated. A Markov decision model simulated the number of maternal life year gained and serodiscordant partner infections averted in the ten years after PMTCT for Option B or B+. ICER per life year gained was calculated. Deterministic sensitivity analyses were conducted. RESULTS: If fully implemented, Option B and Option B+ averted 1016.85 infections and acquired 588,01.02 QALYs.The cost of Option B was US$1,229,338.47, the cost of Option B+ was 1,176,128.63. However, when Options B and B+ were compared over ten years, Option B+ not only improved mothers'ten-year survival from 69.7 to 89.2%, saving more than 3890 life-years, but also averted 3068 HIV infections between serodiscordant partners. Option B+ yielded a favourable ICER of $32.99per QALY acquired in infants and $5149per life year gained in mothers. A 1% MTCT rate, a 90% coverage rate and a 20-year horizon could decrease the ICER per QALY acquired in children and LY gained in mothers. CONCLUSIONS: Option B+ is a cost-effective treatment for comprehensive HIV prevention for infants and serodiscordant partners and life-long treatment for mothers in Yunnan province, China. Option B+ could be implemented in Yunnan province, especially as the goals of elimination mother-to-child transmission of HIV and "90-90-90" achieved, Option B+ would be more attractive.

Point-of-care HIV viral load in pregnant women without prenatal care: a cost-effectiveness analysis.

BACKGROUND: Routine cesarean delivery has been shown to decrease mother-to-child-transmission of HIV in women with high viral load greater than 1000 copies/mL; however, women presenting late in pregnancy may not have viral load results before delivery. OBJECTIVE: Our study investigated the costs and outcomes of using a point-of-care HIV RNA viral load test to guide delivery compared with routine cesarean delivery for all in the setting of unknown viral load. STUDY DESIGN: A decision-analytic model was constructed using TreeAge software to compare HIV RNA viral load testing vs routine cesarean delivery for all in a theoretical cohort of 1275 HIV-positive women without prenatal care who presented at term for delivery, the estimated population of HIV-positive women without prenatal care in the United States annually. TreeAge Pro software is used to build decision trees modeling clinical problems and perform cost-effectiveness, sensitivity, and simulation analysis to identify the optimal outcome. The average cost per test was $15.22. To examine the downstream impact of a cesarean delivery and because most childbearing women in the United States will deliver 2 children, we incorporated a second pregnancy and delivery in the model. Primary outcomes were mother-to-child transmission, delivery mode, cesarean delivery-related complications, cost, and quality-adjusted life years. Model inputs were derived from the literature and varied in sensitivity analyses. The cost-effectiveness threshold was $100,000/quality-adjusted life year. RESULTS: Measuring viral load resulted in more HIV-infected neonates than routine cesarean delivery for all due to viral exposure during more frequent vaginal births in this strategy. There were no observed maternal deaths or differences in cesarean delivery-related complications. Quantifying viral load increased cost by $3,883,371 and decreased quality-adjusted life years by 63 compared with routine cesarean delivery for all. With the threshold set at $100,000/quality-adjusted life year, the viral load test is cost-effective only when the vertical transmission rate in women with high viral load was below 0.68% (baseline: 16.8%) and when the odds ratio of vertical transmission with routine cesarean delivery for all compared with vaginal delivery was above 0.885 (baseline: 0.3). CONCLUSIONS: For HIV-infected pregnant women without prenatal care, quantifying viral load to guide mode of delivery using a point-of-care test resulted in increased costs and decreased effectiveness when compared with routine cesarean delivery for all, even after including downstream complications of cesarean delivery.

Assessing the cost of providing a prevention of mother-to-child transmission of HIV/AIDS service in Ethiopia: urban-rural health facilities setting.

BACKGROUND: While local context costing evidence is relevant for healthcare planning, budgeting and cost-effectiveness analysis, it continues to be scarce in Ethiopia. This study assesses the cost of providing a prevention of mother-to-child transmission of HIV/AIDS (PMTCT) service across heterogeneous prevalence (high, low) and socio-economic (urban, rural) contexts. METHODS: A total of 12 health facilities from six regions in Ethiopia were purposively selected from the latest 2012 antenatal sentinel HIV prevalence report. Six health facilities with the highest HIV prevalence (8.1 to 17.3%) in urban settings and six health facilities with the lowest prevalence (0.0 to 0.1%) in rural settings were selected. A micro-costing approach was applied to identify, measure and value resources used for the provision of a comprehensive PMTCT service. The analysis was conducted across different PMTCT service packages. We also estimated national costs in urban and rural contexts. RESULTS: The average cost per pregnant woman-infant pair per year (PPY) ranged from ETB 6280 (USD 319) to ETB 21,620 (USD 1099) in the urban high HIV prevalence health facilities setting. In rural low HIV prevalence health facilities, the cost ranged from ETB 4323 (USD 220) to ETB 7539 (USD 383).PMTCT service provision in urban health facilities costs more than twice the cost in rural health facilities. The average cost per PPY in an urban setting was more than double the cost in a rural setting due to the higher cost of inputs and possible inefficiencies (although there were a higher number of visits). Consumables (including antiretroviral drugs) and infrastructure were the major cost drivers in both the urban and rural health facilities. Among PMTCT service components, anti-retroviral treatment Option B+ follow-up and counselling accounted for the highest proportion of costs, which ranged from 58 to 72%. Nationally, at the current coverage, the cost of PMTCT service was USD 6 million and USD 3 million in urban and rural settings, respectively. CONCLUSIONS: The analysis suggests that resources used for PMTCT service packages varied across health facilities and HIV prevalence contexts. Providing PMTCT service in the high HIV prevalence urban health facilities costs more than in the rural facilities. Context-specific costing was vital to provide locally sensitive evidence for health service management and priority setting.

Programmes for the prevention of mother-to-child HIV infection transmission have made progress in Yunnan Province, China, from 2006 to 2015: a cost effective and cost-benefit evaluation.

BACKGROUND: Prevention of mother-to-child transmission (PMTCT) of HIV programmes have substantially reduced HIV infections among infants in Yunnan Province, China. We conducted a macro-level economic evaluation of Yunnan's PMTCT programmes over the 10 years from 2006 to 2015 from a policymaker perspective. METHODS: The study methodology was in accordance with the guidelines from the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. We quantified the output from the Yunnan's PMTCT programmes by estimating the number of paediatric HIV infections averted and the relative savings to both the health care system and society. The return-on-investment ratio (ROI) was calculated as the output (numerator) divided by the input (denominator). RESULTS: We have found that the US$ 49 million investment in Yunnan's PMTCT programmes over the period from 2006 to 2015 averted an estimated 2725 new paediatric HIV infections and resulted in an estimated 134,008 QALY acquired. It saved an estimated US$ 0.5 billion in treatment expenditures for Yunnan's healthcare system and nearly US$ 3.9 billion in productivity. The ROI was 88.4, meaning every US$ 1 invested brought about US$ 88.4 in benefits. CONCLUSIONS: Our results support the ongoing investment in PMTCT programmes in Yunnan Province. The PMTCT strategy is a cost effective and cost-benefit strategy in the periods from 2006 to 2015. Despite higher investments in the future, the overall investment in the PMTCT programmes in Yunnan province could be offset by averting more paediatric infections.

Conditional cash transfers to prevent mother-to-child transmission in low facility-delivery settings: evidence from a randomised controlled trial in Nigeria.

BACKGROUND: Nigeria suffers from the highest burden of mother-to-child transmission worldwide. To increase retention in care and prevention programmes, we piloted and evaluated a conditional cash transfer (CCT) programme for preventing mother-to-child transmission (PMTCT) in Akwa Ibom, Nigeria. METHODS: In a randomised controlled trial, pregnant women testing positive for HIV during antenatal care registration at three public hospitals were randomised to one of two study arms: (1) offered enrolment into the CCT programme or (2) continue in standard care for (PMTCT). In the CCT programme, women could receive a compensation package totaling 33,300 Naira (~US$114) for enroling, delivering at the facility, and obtaining a newborn early infant diagnosis (EID) test. The intent-to-treat (ITT) and per protocol (PP) effects of the programme on the primary outcomes of facility delivery and EID testing and on the secondary outcome of nevirapine administration were estimated with logistic regressions. RESULTS: From August 1, 2015 to April 19, 2017, 554 pregnant women tested positive for HIV; 273 were randomised to standard care and 281 were offered enrolment into the CCT intervention. Women offered the CCT programme were more likely to give birth at the facility (n = 109/263; 41.4%) compared to women in standard care (n = 80/254; 31.5%), an absolute difference of 9.9% (OR = 1.54, 95% CI: 1.07-2.21, p = 0.019). For EID testing there was an absolute difference of 12.8% between those offered the CCT intervention (n = 69/263; 26.2%) and those in standard care (n = 34/254; 13.4%; OR = 2.30, 95% CI 1.46-3.62, p = 0.000). PP results show larger differences for both facility deliveries (16.7% absolute difference; OR = 2.02, 95% CI 1.38-2.98, p = 0.000) and EID testing (18.9% absolute difference; OR = 3.09, 95% CI 1.93-4.94, p = 0.000) among intervention enrolees. Over 86% of the facility-delivered newborns received nevirapine, and ITT and PP estimates were similar to those for facility deliveries. CONCLUSIONS: Results show that CCTs improved the likelihood of HIV-positive women giving birth at a facility, of nevirapine being administered to their newborn, and of undergoing EID testing in Akwa Ibom, Nigeria. Effects are especially large among those who agreed to participate in the CCT intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT02447159 , May 18, 2015.

Challenges and opportunities for outreach workers in the Prevention of Mother to Child Transmission of HIV (PMTCT) program in India.

BACKGROUND: The Prevention of Mother-to-Child Transmission of HIV (PMTCT) program in India is one of the largest in the world. It uses outreach workers (ORWs) to facilitate patient uptake of services, however, the challenges faced by the ORWs, and their views about the effectiveness of this program are unknown. METHODS: The COMmunity-Home Based INDia (COMBIND) Prevention of Mother to Child Transmission of HIV study evaluated an integrated mobile health and behavioral intervention to enhance the capacity of ORWs in India. To understand the challenges faced by ORWs, and their perceptions of opportunities for program improvement, four group discussions were conducted among 60 ORW from four districts of Maharashtra, India, as part of the baseline assessment for COMBIND. Data were qualitatively analyzed using a thematic approach. RESULTS: Numerous personal-, social-, and structural-level challenges existed for ORW as they engaged with their patients. Personal-level challenges for ORWs included disclosure of their own HIV status and travelling costs for home visits. Personal-level challenges for patients included financial costs of travelling to ART centers, non-adherence to ART, loss of daily wages, non-affordability of infant formula, lack of awareness of the baby's needs, financial dependence on family, four time points (6weeks, 6 months, 12 months and 18 months) for HIV tests, and need for nevirapine (NVP) prophylaxis. Social-level challenges included lack of motivation by patients and/or health care staff, social stigma, and rude behavior of health care staff and their unwillingness to provide maternity services to women in the PMTCT programme. Structural-level challenges included cultural norms around infant feeding, shortages of HIV testing kits, shortages of antiretroviral drugs and infant NVP prophylaxis, and lack of training/knowledge related to PMTCT infant feeding guidelines by hospital staff. The consensus among ORWs was that there was a critical need for tools and training to improve their capacity to effectively engage with patients, and deliver appropriate care, and for motivation through periodic feedback. CONCLUSIONS: Given the significant challenges in PMTCT programme implementation reported by ORW, novel strategies to address these challenges are urgently needed to improve patient engagement, and access to and retention in care.

HIV-positive pregnant women attending the prevention of mother-to-child transmission of HIV/AIDS (PMTCT) services in Ethiopia: economic productivity losses across urban-rural settings.

HIV/AIDS impacts significantly on pregnant women and on children in Ethiopia. This impact has a multiplier effect on household economies and on productivity losses, and is expected to vary across rural and urban settings. Applying the human capital approach to data collected from 131 respondents, this study estimated productivity losses per HIV-positive pregnant woman-infant pair across urban and rural health facilities in Ethiopia, which in turn were used to estimate the national productivity loss. The study found that the annual productivity loss per woman-infant pair was Ethiopian birr (ETB) 7,433 or United States dollar (US$) 378 and ETB 625 (US$ 32) in urban and rural settings, respectively. The mean patient days lost per year due to inpatient admission at hospitals/health centres was 11 in urban and 22 in rural health facilities. On average, urban home care-givers spent 20 (SD = 21) days annually providing home care services, while their rural counterparts spent 23 days (SD = 26). The productivity loss accounted for 16% and 7% of household income in urban and rural settings, respectively. These high and varying productivity losses require preventive interventions that are appropriate to each setting to ensure the welfare of women and children in Ethiopia.

HIV screening in pregnant women: A systematic review of cost-effectiveness studies.

INTRODUCTION: Vertical transmission represents the major route of HIV infection for children. However, the preventive interventions available are extremely effective. This review summarizes evidence regarding the cost-effectiveness of mother-to-child-transmission preventive screenings, to help policy makers in choosing the optimal antenatal screening strategy. METHODS: A systematic review following PRISMA guidelines was conducted, using 3 databases: PubMed, Scopus, and Cost-Effectiveness Analysis Registry. All articles regarding HIV screening to avoid vertical transmission were included. RESULTS: The review included 21 papers. Seven studies assessed the cost-effectiveness of universal antenatal screening during early gestation. Two papers considered the integration of HIV screening with other medical interventions. Eight works estimated the cost-effectiveness of HIV screening in late pregnancy. Finally, 4 papers considered the combination of multiple strategies. The selected papers focused on both developed and developing countries, with a different HIV prevalence. The characteristics and methodology of the studies were heterogeneous. However, all studies agreed about the main findings, outlining the cost-effectiveness of both universal antenatal screening and HIV rescreening in late pregnancy. Cost-effectiveness improved when HIV burden increased. The major findings were proved to be robust across various scenarios when tested in sensitivity analysis. CONCLUSIONS: The review confirmed the cost-effectiveness not only of HIV universal antenatal screening but also of rescreening in late gestation in both developed and developing countries. Universal screening is cost-effective even in case of extremely low HIV prevalence. Therefore, to maximize screening, coverage appears as a worldwide priority. In certain settings, a targeted screening towards high-risk groups could be a valuable option.