BMJ 1999;319:1230-1234 ( 6 November )

Papers

Cost effectiveness analysis of antenatal HIV screening in United Kingdom

Editorial by Peckham

A E Ades, reader, ^a M J Sculpher, senior research fellow, ^b D M Gibb, senior lecturer in epidemiology, ^a R Gupta, research assistant, ^a J Ratcliffe, research fellow. ^c

^a Department of Epidemiology and Public Health, Institute of Child Health, London WC1N 1EH, ^b Centre for Health Economics, York University, Heslington, York YO10 5DD, ^c Health Economics Research Group, Brunel University, Uxbridge, Middlesex UB8 3PH

Correspondence to: A E Ades a.ades{at}ich.ucl.ac.uk

Objective: To assess the cost effectiveness of universal antenatal HIV screening compared with selective screening in the United Kingdom.
Design: Incremental cost effectiveness analysis relating additional costs of screening to life years gained. Maternal and paediatric costs and life years were combined.
Setting: United Kingdom.
Main outcome measures: Number of districts for which universal screening would be cost effective compared with selective screening under various conditions.
Results: On base case assumptions, a new diagnosis of a pregnant woman with HIV results in a gain of 6.392 life years and additional expenditure of £14 833. If decision makers are prepared to pay up to £10 000 for an additional life year, this would imply a net benefit of £49 090 (range £12 300-£59 000), which would be available to detect each additional infected woman in an antenatal screening programme. In London, universal antenatal screening would be cost effective compared with a selective screening under any reasonable assumptions about screening costs. Outside London, universal screening with uptake above 90% would be cost effective with a £0.60 HIV antibody test cost and up to 3.5 minutes for pretest discussion. Cost effectiveness of universal testing is lower if selective testing can achieve high uptake among those at higher risk. A universal strategy with only 50% uptake may not be less cost effective in low prevalence districts and may cost more and be less effective than a well run selective strategy.
Conclusions: Universal screening with pretest discussion should be adopted throughout the United Kingdom as part of routine antenatal care as long as test costs can be kept low and uptake high.

Key messages In 1997 only 13% of undiagnosed HIV infection in pregnant women was picked up on antenatal testing, resulting in many preventable paediatric infections Assuming NHS willingness to pay £10 000 per life year gained, universal testing would be much more cost effective than selective testing throughout London on any reasonable assumptions on costs, prevalence, and uptake of testing Outside London, universal testing would also be cost effective, even allowing 2-4 minutes for pretest discussion, provided that test costs were no more than £0.60 and uptake exceeded 90% Low cost tests could be achieved by pooling antenatal sera or centralisation of testing Universal testing with uptake of 50% may be less cost effective than a well run selective programme

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