The study comprehensively evaluated a cost-effectiveness analysis of different program components in PMTCT which spanned from HIV counseling and testing to providing substitute feeding in a low incidence, low-middle income setting using Philippines as the case study. In addition, this is the first economic evaluation that analyzed combination of PMTCT interventions including raltegravir intensification for late ART and the first PMTCT economic evaluation done in the country. For countries intending to cover or update their coverage on the combination of PMTCT interventions, the study may assist them by illustrating a model template for HIV screening program among pregnant women.
From the country’s perspective, HIV testing can be a major cost constraint for PMTCT. Reducing the cost of HIV test for HIV-negative pregnant women by 46% will be the most feasible option for the policy strategy to be cost-effective. Also, due to the expected rise in the prevalence of pregnant women needing PMTCT, the probability of the policy strategy to become good value for money will increase. It should also be taken consideration that the threshold used to compare the computed ICER values was around one Gross Domestic Product (GDP) per capita of the country, which was used in previous economic evaluations conducted in Philippine context as suggested in the Philippine National Formulary guidelines.
Twenty-one cost-effectiveness analyses included in the systematic review published by Bert et al. in 2018 had agreed on the cost-effectiveness of universal antenatal screening [7]. However, due to heterogenous characteristics of the countries and methodologies applied to the studies, several factors may have heavy influence on the results of the studies. These include perspective of the study, interventions used for the policy strategy, HIV prevalence per country, and the income level of country setting, which may determine the threshold used to compare the ICER value.
Perspectives used by similar studies conducted may be simply classified either societal, which included the PMTCT costs along with lifetime costs for the HIV-positive women and the perinatally infected newborns, or government payer, where the focus was mostly providing PMTCT and treatment only to the infected newborn [7]. Government payer perspective may underestimate the benefit of providing the universal HIV test due to several reasons. First, the detection of HIV among pregnant women may prompt additional detection among their respective partners as well as prevent further transmission of HIV on their succeeding pregnancies. In fact, according to the study of Kendall [34], the most promising opportunity of women to determine their HIV status is during their pregnancy. When the pregnant women were not diagnosed during their ANC, the most probable next event that would trigger seeking relevant care will be during their won experiences AIDS-related complications or those of a close family member’s. Time period for providing appropriate care for HIV is critical to prevent HIV perinatal transmission. Therefore, HIV diagnosis must be performed as early as possible, wherein ANC visit may serve as a good entry point for any country setting [5]. Prevention of addressing more progressed stages of HIV that would incur additional costs and decrease their overall QALYs were not accounted in government payer perspective. Second, the consequences on the women after delivery due to cesarean section was not assessed. These include higher rates of infectious complications and surgical traumas, longer hospital stay and in-hospital deaths [35]. Although it is proven on systematic reviews that cesarean section provides less risk of maternal HIV transmission, the consequences of maternal injuries were not included in the payer’s perspective. Third, by including only the lifetime treatment costs of infected newborns, the productivity contribution of these population due to increased lifetime was also not considered.
The interventions used in the PMTCT policy strategies of the studies included in the systematic review contained a screening strategy (universal or targeted), with ART and prophylaxis to the newborn with or without considering the health of the woman after her labor [7]. Although most of the studies included considered retesting during late pregnancies, which was not considered in this study, none had investigated the addition of raltegravir as an additional intervention during HIV detection in late pregnancies. The published study by Puthanakit et al. conducted in Thailand showed that providing raltegravir on top of the standard of care for those diagnosed with HIV on late pregnancies drastically reduces the risk of perinatal HIV transmission [21]. This finding was deemed significant in the development of the optimal PMTCT policy strategy. Furthermore, the conducted study was novel in terms of considering how to design an appropriate and feasible PMTCT policy strategy for any country setting who will start to publicly cover PMTCT interventions.
The national prevalence from passive surveillance of HIV-positive pregnant women in the Philippines is around 0.0248% in 2019, which is considered as low prevalence according to UNAIDS [9], [36]. This level of prevalence is comparable to Australia, New Zealand, and Hong Kong but has lower prevalence compared to India, Thailand, Uganda. and South Africa [4], [37]–[42]. All of these countries included suggested that PMTCT interventions including universal HIV screening among pregnant women is cost-effective in their respective country setting [7]. As determined in the univariate sensitivity analysis, prevalence was identified parameters that has great influence on the ICER value. Higher prevalence, with similar income levels and threshold level utilized, would easily make the PMTCT policy strategy good value for money, especially since the prevalence in those countries is higher than the Philippines, with ranges from 1.63–19.5% [38], [39], [41], [43]. However, those countries with comparable prevalence with the Philippines were high income countries and had a much greater threshold used to compare with their ICER values [44]. Compared to the PH threshold of ₱150,000/QALY gained, which is around US$3,000, high-prevalence countries used the estimate values US$17,600, US$24,000, US$10,100 for New Zealand, Australia, and Hong Kong respectively as thresholds for good value of money [37], [40], [41].
Among the sensitive parameters in the univariate sensitivity analysis, the cost of HIV screening can be adjusted by the government payer. One method that was performed in the study is group HIV pre-test counseling, in order to reduce the total amount of time spent of the health worker for counselling, as well as to address the foreseen insufficiency on the number of health workers available. According to the WHO Guidance on testing and counselling for HIV, in order to improve access, a combination of group health information talks to be followed by individual risk based assessments tailored to the patient’s HIV status is a valid method to find a balance between complicated and overdrawn counselling sessions and rapid, intense education/information transfer [45]. As demonstrated in the study, for the case of Philippines, a group HIV pre-testing counselling of at least three persons per session will make the PMTCT policy strategy cost-effective. To add, communities with limited number of health workers may benefit the most of this technique by organizing health information sessions attended by all the people in the community [46]. Also, the local HIV patient group in the Philippines have stated that their organization have trained their members to become qualified peer HIV counselors in order to supplement the lack of health workers proficient in HIV counselling in the country.
The study has its limitations whenever it will be used as a model template for countries that will consider coverage of HIV test among pregnant women. First, several assumptions on the input parameters were made due to unavailability of specific data needed. By assuming equal efficacy of treatment regimens described in Hoffman et al, with the HAART regimens listed current WHO, guidelines may underestimate the benefits gained by reducing the rate of MTCT due to HAART alone [13], [20]. Adaptation and adjustments of foreign data on the utility values of HIV-infected newborns, cost of raltegravir, and lifetime costs of providing treatment for HIV-positive newborns were due to absence of local studies. Second, only direct medical costs were considered in the study. Accounting for productivity costs (e.g. cost of sick leaves and hospitalizations due to HIV complications) and the direct non-medical costs (e.g. travel cost) along with inclusion of costs of adverse events due to treatment regiments in the course of pregnancy, treatment costs of long term side effects to the women and children receiving PMTCT interventions and ARV resistant women and children may provide truer estimate of costs and benefits. Third, the study also did not account for the additional benefits due to early HIV detection and treatment including the prevention of MTCT on succeeding pregnancies, as well as slowing down disease progression of women and their partners. Fourth, any cultural or social factors that may indirectly contribute to the costs and benefits of the program was not explored. To illustrate, published studies from Uganda and England, revealed that HIV patients travel significantly farther to access healthcare than those without HIV. Factors may include lack of necessary specialty services, supply of ART, and possibly to protect confidentiality [47], [48]. Therefore, local feasibility studies must supplement before actual program implementation to determine other technical, political, economic or practical barriers that may impede the operation of the HIV testing program.
HIV/AIDS is not just a health problem, the spread of this infectious disease is highly correlated with socioeconomic, environmental and ecological factors such as population growth, environmental and land-use changes, changing human behaviors and political reorganizations [1]. The research conducted illustrated novel ways how to design cost-effective PMTCT policy strategies in a low income and low prevalence setting. By introducing adjustment methods of the parameters, these imply that for countries with low prevalence, PMTCT strategies coverage may be implemented accordingly. The recognition of maternal HIV transmission as a public health concern in the country must trigger the implementation of PMTCT policies. In such cases where there are underreporting of HIV cases along with the uncontrollable rise in the number of in the Philippines as mentioned by local expert consultations, the consideration for a full-scale implementation of PMTCT must be realized. Furthermore, although the research used scenarios based on actual global practices, outdated practice such as performing cesarean section on HIV-positive pregnant women, regardless of their viral load levels should be discontinued [49]. Knowledge on the recent clinical protocols on the criteria for cesarean section must be enforced.