Background: A comprehensive approach to preventing HIV infection in infants has been recommended, including: (a) preventing HIV in young women, (b) reducing unintended pregnancies among HIV-infected women, (c) preventing vertical transmission (PMTCT), and (d) providing care, treatment, and support to HIV-infected women and their families. Most attention has been given to preventing vertical transmission based on analysis showing nevirapine to be inexpensive and cost-effective.
Methods: The following were determined using data from eight African countries: national program costs and impact on infant infections; reductions in adult HIV prevalence and unintended pregnancies among HIV-infected women that would have equivalent impact on infant HIV infections averted as the nevirapine intervention; and the cost threshold for drugs with greater efficacy than nevirapine yielding an equivalent cost per DALY saved.
Results: Average national annual program cost was $4.8 million. There was, per country, an average of 1898 averted infant HIV infections (US$2517 per HIV infection and US$84 per DALY averted). Lowering HIV prevalence among women by 1.25% or reducing unintended pregnancy among HIV-infected women by 16% yielded an equivalent reduction in infant cases. An antiretroviral drug with 70% efficacy could cost US$152 and have the same cost per DALY averted as nevirapine at 47% efficacy.
Conclusions: Cost-effectiveness of nevirapine prophylaxis is influenced by health system costs, low client uptake, and poor effectiveness of nevirapine. Small reductions in maternal HIV prevalence or unintended pregnancy by HIV-infected women have equivalent impacts on infant HIV incidence and should be part of an overall strategy to lessen numbers of infant infections.
From the aDepartment of International Health, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland USA and the bDepartment of HIV/AIDS, World Health Organization, Geneva, Switzerland.
Correspondence to M. D. Sweat, The Johns Hopkins University, Bloomberg School of Public Health, Department of International Health, 615 North Wolfe St, Room W5523, Baltimore, Maryland 21205, USA.
Received: 10 November 2003; revised: 23 April 2003; accepted: 11 May 2004.