The availability of effective interventions to prevent mother-to-child HIV transmission and the significant reduction in the number of HIV-infected infants in the United States have led to the concept that elimination of mother-to-child HIV transmission (EMCT) is possible. Goals for elimination are presented. We also present a framework by which elimination efforts can be coordinated, beginning with comprehensive reproductive health care (including HIV testing) and real-time case-finding of pregnancies in HIV-infected women, and conducted through the following: facilitation of comprehensive clinical care and social services for women and infants; case review and community action; allowing continuous quality research in prevention and long-term follow-up of HIV-exposed infants; and thorough data reporting for HIV surveillance and EMCT evaluation. It is emphasized that EMCT will not be a one-time accomplishment but, rather, will require sustained effort as long as there are new HIV infections in women of childbearing age.

A Framework for Elimination of Perinatal Transmission of HIV in the United States

Background: The Ministry of Health in Malawi is implementing a pragmatic and innovative approach for the management of all HIV-infected pregnant women termed Option B+ which consists of providing life-long antiretroviral treatment regardless of their CD4 count or clinical stage. Our objective was to determine if Option B+ represents a cost-effective option. Methods: A decision model simulates the disease progression of a cohort of HIV-infected pregnant women receiving prophylaxis and antiretroviral therapy and estimates the number of paediatric infections averted and maternal life years gained over a ten-year time horizon. We assess the cost-effectiveness from the Ministry of Health perspective while taking into account the practical realities of implementing ART services in Malawi. Results: If implemented as recommended by the World Health Organization options A B and B+ are equivalent in preventing new infant infections yielding cost effectiveness ratios between US$ 37 and US$ 69 per disability adjusted life year averted in children. However when the three options are compared to the current practice the provision of antiretroviral therapy to all mothers (Option B+) not only prevents infant infections but also improves the ten-year survival in mothers more than four-fold. This translates into saving more than 250000 maternal life years as compared to mothers receiving only Option A or B with savings of 153000 and 172000 life years respectively. Option B+ also yields favourable incremental cost effectiveness ratios (ICER) of US$ 455 per life year gained over the current practice. Conclusion: In Malawi Option B+ represents a favorable policy option from a cost-effectiveness perspective to prevent future infant infections save mothers lives and reduce orphanhood. Although Option B+ would require more financial resources initially it would save societal resources in the long-term and represents a strategic option to simplify and integrate HIV services into maternal newborn and child health programmes.

https://www.who.int/hiv/pub/mtct/HIV_MCTC_B_MalawiPlosONE.pdf

Cost-Effectiveness Analysis of Option B+ for HIV Prevention and Treatment of Mothers and Children in Malawi.

OBJECTIVE. The objective of this study was to describe trends in hospital use by HIV-infected children and adolescents in the United States in the 10 years from 1994 (before highly active antiretroviral therapy) to 2003 (widespread use of highly active antiretroviral therapy). METHODS. Data from the Nationwide Inpatient Sample database were used. The most frequent diagnoses were evaluated by year, and trends in hospitalizations for selected diagnoses and procedures were examined by multivariate logistic regression. RESULTS. In 2003, there were an estimated 3419 hospitalizations of HIV-infected children who were 18 years or younger, compared with 11785 such hospitalizations in 1994 (a 71% decrease). This decrease was more marked among infants and children who were younger than 5 years (94% for boys and 92% for girls) than among adolescents (decrease of 47% for boys and increase of 23% for girls 15–18 years of age). The inpatient fatality rate among HIV-infected children decreased from 5.0% in 1994 to 1.8% in 2003. The number of hospitalizations among HIV-infected children in the highly active antiretroviral therapy era decreased significantly compared with before highly active antiretroviral therapy (1994–1996) for Pneumocystis jiroveci, bacterial infection, or sepsis; fungal infection; encephalopathy; failure to thrive; and lymphocytic interstitial pneumonia. No significant change in the number of hospitalizations for Pneumococcus or cytomegalovirus was observed. CONCLUSIONS. Dramatic decreases in the number of hospitalizations among HIV-infected children occurred since the advent of highly active antiretroviral therapy in the United States. However, this trend is not seen in hospitalizations of adolescents, particularly girls. Hospitalizations for several HIV-related conditions are less frequent in the highly active antiretroviral therapy era, but for certain other conditions, the hospitalization burden remains high.

Trends in Hospitalizations of HIV-Infected Children and Adolescents in the United States: Analysis of Data From the 1994–2003 Nationwide Inpatient Sample

PURPOSE OF REVIEW: Increasing number of people living with HIV (PLHIV) will require expanded access to health services. Countries need robust and contemporary strategic information on the cost of care to monitor and evaluate the effectiveness efficiency equity and acceptability of services. Published HIV cost literature from July 1999 to December 2008 was reviewed. Articles were identified using specific databases and scored based on explicit criteria relating to the services covered utilization data cost data used and quality of the study. RECENT FINDINGS: One hundred and fifteen articles were identified 47% came from North America 29% from Europe 17% from Africa and 8% from Asia; no studies from Latin America could be identified. The mean score across all studies was 33.7 out of a maximum of 64 with a median of 34 and a range of 11-51. Mean score did not change significantly over time (Pearsons R8 = 0.3; P > 0.05). SUMMARY: Great variation was observed in the methods used to estimate cost data across the studies identified including range of services patients covered and outcomes costed. Progress in the quantity and quality of studies published since 1999 has been limited. More consistent costing methods and more comprehensive coverage - both by country and level of care - are needed in order for policymakers and other stakeholders to be able to optimally monitor and evaluate the cost and cost-effectiveness of country services for HIV treatment and care especially as population costs are likely to increase with more PLHIV on antiretroviral therapy.

The cost of treatment and care for people living with HIV infection: implications of published studies, 1999-2008.

Background: Infant mortality is an important indicator of population health in a country. It is associated with several health determinants, such as maternal health, access to high-quality health care, socioeconomic conditions, and public health policy and practices. Methods: A spatial-temporal analysis was performed to assess changes in infant mortality patterns between 1992-2007 and to identify factors associated with infant mortality risk in the Agincourt sub-district, rural northeast South Africa. Period, sex, refugee status, maternal and fertility-related factors, household mortality experience, distance to nearest primary health care facility, and socio-economic status were examined as possible risk factors. All-cause and cause-specific mortality maps were developed to identify high risk areas within the study site. The analysis was carried out by fitting Bayesian hierarchical geostatistical negative binomial autoregressive models using Markov chain Monte Carlo simulation. Simulation-based Bayesian kriging was used to produce maps of allcause and cause-specific mortality risk. Results: Infant mortality increased significantly over the study period, largely due to the impact of the HIV epidemic. There was a high burden of neonatal mortality (especially perinatal) with several hot spots observed in close proximity to health facilities. Significant risk factors for all-cause infant mortality were mother’s death in first year (most commonly due to HIV), death of previous sibling and increasing number of household deaths. Being born to a Mozambican mother posed a significant risk for infectious and parasitic deaths, particularly acute diarrhoea and malnutrition. Conclusions: This study demonstrates the use of Bayesian geostatistical models in assessing risk factors and producing smooth maps of infant mortality risk in a health and socio-demographic surveillance system. Results showed marked geographical differences in mortality risk across a relatively small area. Prevention of vertical transmission of HIV and survival of mothers during the infants’ first year in high prevalence villages needs to be urgently addressed, including expanded antenatal testing, prevention of mother-to-child transmission, and improved access to antiretroviral therapy. There is also need to assess and improve the capacity of district hospitals for emergency obstetric and newborn care. Persisting risk factors, including inadequate provision of clean water and sanitation, are yet to be fully addressed.

/pdf/young-and-vulnerable-spatial-temporal-trends-and-risk-502fvolkea.pdf

Young and vulnerable: Spatial-temporal trends and risk factors for infant mortality in rural South Africa (Agincourt), 1992-2007

Objectives: This study examined changes in healthcare use among perinatally HIV-infected children and developed new estimates of expected lifetime treatment costs. Methods: The study analyzed longitudinal medical record data from the Pediatric Spectrum of Disease study on perinatally HIV-infected children enrolled in 6 US sites during 1995 and 2001 for enrollee characteristics including healthcare utilization. For the year 2001, costs were assigned to hospitalization, HIV-related drug usage, and laboratory testing. To estimate lifetime treatment costs based on those categories, median survival times of 9, 15, and 25 years were assumed and average annual healthcare utilization costs were applied to each year of survival. Results: From 1995 to 2001, hospitalization rates fell from 0.67 per child-year to 0.23 per child-year (P < 0.05). In 2001, the average cost of healthcare utilization per child was $12,663, including $2164 for hospitalization, $9505 for HIV-related drugs, and $994 for laboratory tests. The discounted lifetime treatment cost, based on those 3 cost categories, was $113,476 for 9 years of survival, $151,849 for 15 years, and $228,155 for 25 years. Conclusions: Hospitalizations among perinatally HIV-infected children decreased significantly from 1995 to 2001. Compared with previously published estimates, lifetime treatment costs for children perinatally infected with HIV have remained relatively stable. However, as years of survival increase for this population, lifetime costs also are likely to increase.

Mary Jo Earp

Papers

Updated estimates of healthcare utilization and costs among perinatally HIV-infected children