BMJ 1999;318:1650-1656 ( 19 June )

Papers

Prevention of vertical transmission of HIV: analysis of cost effectiveness of options available in South Africa

Papers pp   1656 , 1660

Neil Söderlund, health economist, a Karen Zwi, senior lecturer, b Anthony Kinghorn, health economist, c Glenda Gray, director. d

a Centre for Health Policy, University of the Witwatersrand PO Box 1038, Johannesburg 2000, South Africa, b Department of Paediatrics, Chris Hani Baragwanath Hospital, Johannesburg, South Africa, c Abt Associates South Africa, Johannesburg, South Africa, d Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa

Correspondence: Dr Söderlund soderlun{at}icon.co.za

Objective: To assess the cost effectiveness of vertical transmission prevention strategies by using a mathematical simulation model.
Design: A Markov chain model was used to simulate the cost effectiveness of four formula feeding strategies, three antiretroviral interventions, and combined formula feeding and antiretroviral interventions on a cohort of 20 000 pregnancies. All children born to HIV positive mothers were followed up until age of likely death given current life expectancy and a cost per life year gained calculated for each strategy.
Setting: Model of working class, urban South African population.
Results: Low cost antiretroviral regimens were almost as effective as high cost ones and more cost effective when formula feeding interventions were added. With or without formula feeding, low cost antiretroviral interventions were likely to save lives and money. Interventions that allowed breast feeding early on, to be replaced by formula feeding at 4 or 7 months, seemed likely to save fewer lives and offered poorer value for money.
Conclusions: Antiretroviral interventions are probably cost effective across a wide range of settings, with or without formula feeding interventions. The appropriateness of formula feeding was highly cost effective only in settings with high seroprevalence and reasonable levels of child survival and dangerous where infant mortality was high or the protective effect of breast feeding substantial. Pilot projects are now needed to ensure the feasibility of implementation.


Key messages

  • Despite favourable trial results many developing countries are unsure of the appropriateness of implementing antenatal screening and prevention programmes for vertical transmission of HIV

  • Screening and administration of antiretroviral drugs around birth is likely to be a cost effective intervention across a wide range of settings, irrespective of mode of feeding

  • Recommendation of formula feeding for babies of HIV positive mothers is contraindicated in areas of high infant mortality

  • Simulation modelling might assist decision makers to weigh up the relative advantages and disadvantages of strategies for prevention of vertical transmission in their own areas

  • Pilot projects are required to test feasibility and acceptability of such strategies




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