Is single-dose NVP relevant in the era of more efficacious PMTCT regimens? Lessons from Zambia.

For almost a decade, single-dose nevirapine (sdNVP) has been proven to be a safe and effective drug for the prevention of mother-to-child transmission (PMTCT) of HIV. With the advent of the use of more efficacious combination therapy strategy in reducing mother-to-child transmission, sdNVP has been relegated as a lower tier intervention. Availability of infrastructural capacity coupled with the practical reality that very few women attend an antenatal clinic more than once makes universal implementation of combination therapy a challenge. This retrospective review examined PMTCT programmatic indicators following the introduction of sdNVP at first contact in selected sites. Data from 79 PMTCT sites was reviewed from April 2006 to March 2007 (when sdNVP was offered only after 32 weeks) and compared to the period of April 2007-March 2008. In the pre-intervention period (April 2006-March 2007), the monthly average of pregnant women who received sdNVP per site was 5.02. Post-intervention (April 2007-March 2008), the monthly average increased by 59% to 7.97 (p-value<0.05). In pre-intervention period when sdNVP was dispensed at 32 weeks, the average proportion of pregnant women who received antiretroviral prophylaxis was 59%. This increased to 82% after the intervention. Current systems for dispensing sdNVP may be used as a foundation for implementation of more efficacious PMTCT regimens. The sdNVP administered at first contact should be a safety net for women who are unable to receive more efficacious regimen.

Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania.

BACKGROUND: Access to HIV-1 voluntary counselling and testing (VCT) is severely limited in less-developed countries. We undertook a multisite trial of HIV-1 VCT to assess its impact, cost, and cost-effectiveness in less-developed country settings. METHODS: The cost-effectiveness of HIV-1 VCT was estimated for a hypothetical cohort of 10000 people seeking VCT in urban east Africa. Outcomes were modelled based on results from a randomised controlled trial of HIV-1 VCT in Tanzania and Kenya. Our main outcome measures included programme cost, number of HIV-1 infections averted, cost per HIV-1 infection averted, and cost per disability-adjusted life-year (DALY) saved. We also modelled the impact of targeting VCT by HIV-1 prevalence of the client population, and the proportion of clients who receive VCT as a couple compared with as individuals. Sensitivity analysis was done on all model parameters. FINDINGS: HIV-1 VCT was estimated to avert 1104 HIV-1 infections in Kenya and 895 in Tanzania during the subsequent year. The cost per HIV-1 infection averted was US$249 and $346, respectively, and the cost per DALY saved was $12.77 and $17.78. The intervention was most cost-effective for HIV-1-infected people and those who received VCT as a couple. The cost-effectiveness of VCT was robust, with a range for the average cost per DALY saved of $5.16-27.36 in Kenya, and $6.58-45.03 in Tanzania. Analysis of targeting showed that increasing the proportion of couples to 70% reduces the cost per DALY saved to $10.71 in Kenya and $13.39 in Tanzania, and that targeting a population with HIV-1 prevalence of 45% decreased the cost per DALY saved to $8.36 in Kenya and $11.74 in Tanzania. INTERPRETATION: HIV-1 VCT is highly cost-effective in urban east African settings, but slightly less so than interventions such as improvement of sexually transmitted disease services and universal provision of nevirapine to pregnant women in high-prevalence settings. With the targeting of VCT to populations with high HIV-1 prevalence and couples the cost-effectiveness of VCT is improved significantly.