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Early infant HIV testing at birth and at 6 weeks of age will save lives, extend life expectancy and is cost-effective for South Africa, study finds
Michael Carter, 2016-09-22 08:30:00
Early infant HIV
diagnosis in South Africa will save lives, extend life expectancy and be cost-effective, according to a modelling study published in the online edition of
the Journal of Infectious Diseases.
Compared to no early infant diagnosis (EID), testing at either birth or 6
weeks of life reduced one-year mortality rates, led to a longer life expectancy
and was cost-effective. Testing at both birth and 6 weeks had further benefits.
The author of an
editorial comment on the study praised it as “an elegant analysis…of the
expected clinical impact and cost-effectiveness of different strategies of
early infant diagnosis in South Africa.”
are approximately 150,000 infant HIV infections each year. Without
antiretroviral therapy (ART), mortality in infants with HIV reaches between
50 and 65% by the age of 2 years. Three-quarters of these deaths could be
prevented with prompt ART, but this requires early infant diagnosis. The World Health Organization
therefore recommends that all HIV-exposed infants should be screened for
infection using a nucleic acid amplification test (NAT) at the age of 6 weeks.
to this strategy have been proposed as some infants contract the infection in the womb
and have a significant mortality risk before screening at 6 weeks of age.
Testing twice, at birth and 6 weeks of age, has therefore been suggested as an enhanced
Using data from
South Africa, investigators modelled the clinical benefits and
cost-effectiveness of four early infant diagnosis strategies:
- No early infant diagnosis.
- Testing once – birth.
- Testing once – 6 weeks of age.
- Testing twice – birth and 6
weeks of age.
included short- and long-term survival, life expectancy and HIV-related
healthcare costs. Outcomes for HIV-infected and HIV-negative infants were
modelled separately. The investigators also calculated the incremental
cost-effectiveness ratio (ICER) for each strategy compared to the next least
alternative. Interventions with ICERs below 50% of South Africa’s per capita
gross domestic product (GDP) - $3,250 - were considered cost effective. Further
analysis took into account the impact of different levels of engagement with
the HIV testing and care cascade on the clinical benefits and cost
effectiveness of each testing strategy.
The model was
based on a mother-to-child HIV transmission rate of 5%, with 2% of infections
occurring in the womb, 1% at birth and 2% postpartum.
No early infant
diagnosis would lead to a 35% one-year mortality rate among HIV-infected
infants, who had an overall life expectancy of 21 years.
increased substantially with any early infant diagnosis strategy – assuming
100% testing, result return and linkage to care.
Testing at birth
alone was associated with a 28% one-year mortality rate and an overall life expectancy
of 24 years. The six-week alone testing strategy had a 25% one-year mortality
rate and a project life expectancy of 26 years. Testing twice increased
survival, with a 24% one-year mortality rate and a life expectancy of 27 years.
There was only a
modest impact on survival, regardless of testing strategy, for the
HIV-uninfected infants, with one-year survival rates of approximately 93% and a
life expectancy of approximately 61 years.
No early infant
diagnosis had lifetime costs of $1,430 per HIV-exposed infant. Testing at birth
alone had lifetime costs of $1,670 for each HIV-exposed infant, increasing to
$1,770 with once-only testing at 6 weeks. Testing twice was associated with a
lifetime cost per HIV-exposed infant of $1,840.
cost-effectiveness analysis testing at birth dominated. The ICER for 6 weeks
alone was $1,250/year life saved, 19% of South Africa’s per capita GDP. The
ICER for testing twice versus 6 weeks only was $2900/year life saved, (45% of per
analyses, all testing strategies remained cost effective (compared to no
testing) when most scenarios were modelled, only equaling over 50% of per
capita GDP with very low levels of testing, testing accuracy, test return,
linkage to care and ART uptake and effectiveness. In a further analysis,
increasing linkage to care and ART uptake with testing at 6 weeks alone
improved survival more than adding a second test at birth.
“We find that
current EID recommendations to test once at 6 weeks alone markedly improve
infant outcomes and are good value in South Africa compared to no EID,”
conclude the investigators. “Testing twice, at birth and 6 weeks, will further
improve outcomes and be cost-effective when uptake is high. If scale-up costs
are comparable, policymakers should add birth testing after optimizing 6-week
EID programs, alongside careful attention to retaining infants with negative
birth test results in care.”
The author of the
editorial emphasizes that early infant diagnosis just the first step in
improving outcomes among HIV-infected infants, writing “it requires ensuring
linkage to an effective longitudinal care system with age-appropriate
antiretroviral drugs and rapid initiation of therapy for HIV-infected infants
(and their parents).”