Cost-effectiveness of Routine Provider-Initiated Testing and Counseling for Children With Undiagnosed HIV in South Africa

Tijana Stanic; Nicole McCann; Martina Penazzato; Clare Flanagan; Shaffiq Essajee; Kenneth A Freedberg; Meg Doherty; Nande Putta; Landon Myer; George K Siberry; Intira Jeannie Collins; Lara Vojnov; Elaine Abrams; Djøra I Soeteman; Andrea L Ciaranello

doi:10.1093/ofid/ofab603

Cost-effectiveness of Routine Provider-Initiated Testing and Counseling for Children With Undiagnosed HIV in South Africa

Open Forum Infect Dis. 2021 Dec 5;9(1):ofab603. doi: 10.1093/ofid/ofab603. eCollection 2022 Jan.

Authors

Tijana Stanic¹, Nicole McCann¹, Martina Penazzato², Clare Flanagan¹, Shaffiq Essajee³, Kenneth A Freedberg^{1

4

5

6}, Meg Doherty², Nande Putta³, Landon Myer⁷, George K Siberry⁸, Intira Jeannie Collins⁹, Lara Vojnov², Elaine Abrams^{10

11}, Djøra I Soeteman^{1

12}, Andrea L Ciaranello^{1

4

5}

Affiliations

¹ Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
² Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
³ UNICEF, New York, New York, USA.
⁴ Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
⁵ Harvard Medical School, Boston, Massachusetts, USA.
⁶ Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
⁷ School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
⁸ Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA.
⁹ MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK.
¹⁰ ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, USA.
¹¹ Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA.
¹² Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.

Abstract

Background: We compared the cost-effectiveness of pediatric provider-initiated HIV testing and counseling (PITC) vs no PITC in a range of clinical care settings in South Africa.

Methods: We used the Cost-Effectiveness of Preventing AIDS Complications Pediatric model to simulate a cohort of children, aged 2-10 years, presenting for care in 4 settings (outpatient, malnutrition, inpatient, tuberculosis clinic) with varying prevalence of undiagnosed HIV (1.0%, 15.0%, 17.5%, 50.0%, respectively). We compared "PITC" (routine testing offered to all patients; 97% acceptance and 71% linkage to care after HIV diagnosis) with no PITC. Model outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs) from the health care system perspective and the proportion of children with HIV (CWH) diagnosed, on antiretroviral therapy (ART), and virally suppressed. We assumed a threshold of $3200/year of life saved (YLS) to determine cost-effectiveness. Sensitivity analyses varied the age distribution of children seeking care and costs for PITC, HIV care, and ART.

Results: PITC improved the proportion of CWH diagnosed (45.2% to 83.2%), on ART (40.8% to 80.4%), and virally suppressed (32.6% to 63.7%) at 1 year in all settings. PITC increased life expectancy by 0.1-0.7 years for children seeking care (including those with and without HIV). In all settings, the ICER of PITC vs no PITC was very similar, ranging from $710 to $1240/YLS. PITC remained cost-effective unless undiagnosed HIV prevalence was <0.2%.

Conclusions: Routine testing improves HIV clinical outcomes and is cost-effective in South Africa if the prevalence of undiagnosed HIV among children exceeds 0.2%. These findings support current recommendations for PITC in outpatient, inpatient, tuberculosis, and malnutrition clinical settings.

Keywords: HIV; PITC; cost-effectiveness; pediatric.

Abstract

Grants and funding