Estimated costs for the delivery of safer conception strategies for HIV-discordant couples in Zimbabwe: a cost analysis
Carolyn Smith Hughes, Joelle Brown, Caroline Murombedzi, Thandiwe Chirenda, Gift Chareka, Felix Mhlanga, Bismark Mateveke, Serah Gitome, Tinei Makurumure, Allen Matubu, Nyaradzo Mgodi, Zvavahera Chirenje, James G Kahn, Carolyn Smith Hughes, Joelle Brown, Caroline Murombedzi, Thandiwe Chirenda, Gift Chareka, Felix Mhlanga, Bismark Mateveke, Serah Gitome, Tinei Makurumure, Allen Matubu, Nyaradzo Mgodi, Zvavahera Chirenje, James G Kahn
Abstract
Background: In recent years, safer conception strategies have been developed to help HIV-serodiscordant couples conceive a child without transmitting HIV to the seronegative partner. The SAFER clinical trial assessed implementation of these strategies in Zimbabwe.
Methods: As a part of the SAFER study, we estimated the costs (in 2017 $US) associated with individual and combination strategies, in the trial setting and real-world practice, from a healthcare system perspective. Safer conception strategies included: 1) ART with frequent viral load testing until achieving undetectable viral load (ART-VL); 2) daily oral pre-exposure prophylaxis (PrEP); 3) semen-washing with intrauterine insemination; and 4) manual self-insemination at home. For costs in the trial, we used a micro-costing approach, including a time and motion study to quantify personnel effort, and estimated the cost per couple for individual and combination strategies for a mean of 6 months of safer services. For real-world practice, we modeled costs for three implementation scenarios, representing differences from the trial in input prices (paid by the Ministry of Health and Child Care [MOHCC]), intervention intensity, and increments to current HIV prevention and treatment practices and guidelines. We used one-way sensitivity analyses to assess the impact of uncertainty in input variables.
Results: Individual strategy costs were $769-$1615 per couple in the trial; $185-$563 if using MOHCC prices. Under the target intervention intensity and using MOHCC prices, individual strategy costs were $73-$360 per couple over and above the cost of current HIV clinical practices. The cost of delivering the most commonly selected combination, ART-VL plus PrEP, ranged from $166-$517 per couple under the three real-world scenarios. Highest costs were for personnel, lab tests, and strategy-specific consumables, in variable proportions by clinical strategy and analysis scenario. Total costs were most affected by uncertainty in the price of PrEP, number of semen-washing attempts, and scale-up of semen-washing capacity.
Conclusions: Safer conception methods have costs that may be affordable in many low-resource settings. These cost data will help implementers and policymakers add safer conception services. Cost-effectiveness analysis is needed to assess value for money for safer conception services overall and for safer strategy combinations.
Trial registration: Registry Name: Clinicaltrials.gov.
Trial registration number: NCT03049176 . Registration date: February 9, 2017.
Keywords: ART; Conception; Cost; Discordant; HIV; PrEP; Semen-washing.
Conflict of interest statement
There are no competing interests to report.
Figures
References
- Ministry of Health and Child Care (MOHCC), Zimbabwe. Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) 2015–2016: Final Report. August 2019, Harare: MOHCC.
- Asfaw HM, Gashe FE. Fertility intentions among HIV positive women aged 18–49 years in Addis Ababa Ethiopia: a cross sectional study. Reprod Health. 2014;11(36). 10.1186/1742-4755-11-36.
- Krashin JW, Haddad LB, Tweya H, et al. Factors associated with desired fertility among HIV-positive women and men attending two urban clinics in Lilongwe, Malawi. PLoS One. 2018;13(6):e0198798. doi: 10.1371/journal.pone.0198798.
- Schwartz SR, Mehta SH, Taha TE, Rees HV, Venter F, Black V. High pregnancy intentions and missed opportunities for patient-provider communication about fertility in a south African cohort of HIV-positive women on antiretroviral therapy. AIDS Behav. 2012;16(1):69–78. doi: 10.1007/s10461-011-9981-3.
- Tweya H, Feldacker C, Breeze E, et al. Incidence of pregnancy among women accessing antiretroviral therapy in urban Malawi: A retrospective cohort study. AIDS Behav. 2013;17:471. .
- Matthews LT, Beyeza-Kashesya J, Cooke I, Davies N, Heffron R, Kaida A, et al. Consensus statement: supporting safer conception and pregnancy for men and women living with and affected by HIV. AIDS Behav. 2018;22(6):1713–1724. doi: 10.1007/s10461-017-1777-7.
- Brown JM, Njoroge B, Akama E, Breitnauer B, Leddy A, Darbes L, et al. A novel safer conception counseling toolkit for the prevention of HIV: a mixed methods evaluation in Kisumu, Kenya. AIDS Educ Prev. 2016;28:524–538. doi: 10.1521/aeap.2016.28.6.524.
- Updated recommendations on first-line and second-line antiretroviral regimens and post-exposure prophylaxis and recommendations on early infant diagnosis of HIV: interim guidelines . Supplement to the 2016 consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Geneva: World Health Organization; 2018.
- World Health Organization . Recommendations for a public health approach. Second. Geneva: World Health Organization; 2016. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection.
- World Health Organization. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Geneva: World Health Organization; 2015.
- Zimbabwe Ministry of Health and Child Care . PrEP Guidelines. Harare: MOHCC; 2016.
- Zimbabwe Ministry of Health and Child Care . Guidelines for Antiretroviral Therapy for the Prevention and Treatment of HIV in Zimbabwe. Harare: MOHCC; 2016.
- Drummond M. Methods for the economic evaluation of health care programmes. 2nd ed. Oxford. New York: Oxford University Press; 1997.
- Marseille E, Giganti MJ, Mwango A, et al. Taking ART to scale: determinants of the cost and cost-effectiveness of antiretroviral therapy in 45 clinical sites in Zambia. PLoS One. 2012;7:e51993. doi: 10.1371/journal.pone.0051993.
- Webb K, Maclean R, Engelsmann B, et al. Optimizing Zimbabwe’s National PMTCT Program: Cost-effectiveness of a planned village health worker (VHW)-based intervention to improve linkage to postnatal care. Vancouver: Poster presented at: 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention; 2015.
- Vernazza PL, Graf I, Sonnenberg-Schwan U, Geit M, Meurer A. Preexposure prophylaxis and timed intercourse for HIV-discordant couples willing to conceive a child. AIDS. 2011;25(16):2005–2008. doi: 10.1097/QAD.0b013e32834a36d0.
- Joffe M. Time to pregnancy: a measure of reproductive function in either sex. Asclepios project. Occup Environ Med. 1997;54(5):289–295. doi: 10.1136/oem.54.5.289.
- Health Transition Fund A Multi-donor Pooled Transition Fund for Health in Zimbabwe. 2011. . Accessed March 23, 2017.
- Jain V, Chang W, Byonanebye DM, et al. Estimated costs for delivery of HIV antiretroviral therapy to individuals with CD4+ T-cell counts >350 cells/uL in rural Uganda. PLoS One. 2015;10(12):e0143433. doi: 10.1371/journal.pone.0143433.
- Clinton Health Access Initiative. ARV market report: the state of the antiretroviral drug market in low- and middle-income countries. 2016. . Accessed June 19, 2017.
- 2016 ANTIRETROVIRAL (ARV) CHAI REFERENCE PRICE LIST. ARV Ref Price List 2016. . Accessed June 19, 2017.
- Clinton Health Access Initiative. CHAI supports South Africa and global partners to achieve landmark HIV viral load access program. Case Study; 2015. . Accessed 19 June 2017.
- Roche Molecular Systems. Global Access Initiative Country List. July 2015. . Accessed June 19, 2017.
- Kahn JG, Harris B, Mermin J, et al. Cost of community integrated prevention campaign for malaria, HIV, and diarrhea in rural Kenya. BMC Health Serv Res. 2011;11:346. doi: 10.1186/1472-6963-11-346.
- Mack N, Evens EM, Tolley EE, et al. The importance of choice in the rollout of ARV-based prevention to user groups in Kenya and South Africa: a qualitative study. J Int AIDS Soc. 2014;17:19157. doi: 10.7448/IAS.17.3.19157.
- Gray A, Smit J, Manzini N, Beksinska M. Systematic review of contraceptive medicines. “Does choice make a difference?” University of Witwatersrand, Johannesberg. 2006.
- Donnell D, Baeten JM, Bumpus NN, et al. HIV protective efficacy and correlates of tenofovir blood concentrations in a clinical trial of PrEP for HIV prevention. J Acquir Immune Defic Syndr. 2014;66(3):340–348. doi: 10.1097/QAI.0000000000000172.
- Anglemyer A, Rutherford GW, Horvath T, Baggaley RC, Egger M, Siegfried N. Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database Syst Rev. 2013;4(4):CD009153. doi: 10.1002/14651858.CD009153.pub3.
- Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505. doi: 10.1056/NEJMoa1105243.
- Rutstein SE, Ananworanich J, Fidler S, et al. Clinical and public health implications of acute and early HIV detection and treatment: a scoping review. J Int AIDS Soc. 2017;20(1):21579. doi: 10.7448/IAS.20.1.21579.
- Price JT, Wheeler SB, Stranix-Chibanda L, et al. Cost-effectiveness of pre-exposure HIV prophylaxis during pregnancy and breastfeeding in sub-Saharan Africa. J Acquir Immune Defic Syndr. 2016;72:S145–S153. doi: 10.1097/QAI.0000000000001063.
- Cremin I, Hallett TB. Estimating the range of potential epidemiological impact of preexposure prophylaxis: run-away success or run-away failure? AIDS. 2015;29(6): 733–738. .
- Walensky RP, Jacobsen MM, Bekker L-G, et al. Potential clinical and economic value of long-acting Preexposure prophylaxis for south African women at high-risk for HIV infection. J Infect Dis. 2016;213:1523–1531. doi: 10.1093/infdis/jiv523.
- Huyser C, Boyd L. ART in South Africa: the price to pay. Facts Views Vis Obgyn. 2013;5(2):91–99.
Source: PubMed