|Cost-effectiveness estimates for antenatal HIV testing in the Netherlands
|Rozenbaum MH, Verweel G, Folkerts DK, Dronkers F, van den Hoek JA, Hartwig NG, de Groot R, Postma MJ
This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn.
The objective was to examine the cost-effectiveness of universal human immunodeficiency virus screening during pregnancy. The authors concluded that screening was cost-effective from the perspective of the Dutch health care system. On the whole, the study was well conducted and satisfactorily presented, but more details on the clinical sources would have been useful. The authors’ conclusions appear to be robust and valid.
Type of economic evaluation
The objective was to examine the cost-effectiveness of universal human immunodeficiency virus (HIV) screening during pregnancy.
The universal antenatal HIV screening programme was compared with no screening. Women found to be HIV-positive were assumed to receive highly active antiretroviral therapy (HAART) of combivir plus nelvinavir or combivir plus neviparine.
Netherlands/primary care, secondary care, and hospital.
The study was based on a simple model that projected HAART treatment for HIV-infected children over a lifetime. The authors stated that the perspective of the health care system was adopted.
The clinical data appear to have been derived from selected sources, which might have been known to the authors. The prevalence of HIV in pregnant women was derived from a registry maintained by the Public Health Service of Amsterdam, which implemented universal HIV screening among pregnant women between 2003 and 2005. Other estimates were derived from published studies, the details of which were not given. The key clinical endpoint was the rate of mother-to-child HIV transmission.
Monetary benefit and utility valuations:
Measure of benefit:
Life-years (LYs) were the summary benefit measure and were discounted at an annual rate of 1.5%.
The economic analysis included the costs of HIV screening, counselling, HAART drugs, diagnostic tests, delivery, formula feeding, and lifetime health care for infants infected with HIV. The order costs for tests, pharmacist fees for prescriptions, and both medical specialists’ and anaesthesiologists’ fees were included when required. The resource use data were based on published evidence and local patterns of care. Most of the costs were derived from official national prices and previous studies. The costs and quantities for lifetime care of HIV-infected children were derived from a national registry from 1997 to 2003. All costs were in Euros (EUR) and the price year was 2005. When required, a 4% annual discount rate was applied.
Analysis of uncertainty:
A series of one-way sensitivity analyses was carried out on all the inputs to the model. Whenever possible, the ranges of values were based on published estimates, supplemented by authors’ assumptions. Two-way sensitivity analysis was also conducted on the discount rate and HIV prevalence.
At a prevalence rate of 9.3 undiagnosed HIV infections per 10,000 pregnancies, the universal screening strategy reduced costs by EUR 96,707 and saved 74 LYs in comparison with no screening. Under base-case conditions, the universal programme was dominant, which means it was more effective and less costly than no screening.
When the prevalence rate was varied, the cost-effectiveness results changed. The universal programme was no longer cost-saving at a prevalence rate below 6.9, but remained below a threshold of EUR 20,000 per LY gained above a rate of 1.4. Even in the worst-case scenario (prevalence 5.0), HIV screening was cost-effective at EUR 6,495 per LY gained.
The authors concluded that universal antenatal HIV screening was cost-saving or cost-effective from the perspective of the Dutch health care system.
The selection of the comparators was appropriate as the screening programme was compared against the same setting prior to universal programme implementation.
The use of selected sources to identify the relevant data may have limited the validity of the clinical estimates, as a literature review generally provides more comprehensive sources for clinical data. Local data were the best clinical source for prevalence, because they are fully applicable to the study setting. No details of the design or other characteristics of the other published sources were given, which hinders an objective assessment of the data quality. The authors did not describe the approach used to select the most appropriate estimate from the sources and did not raise the issue of the comparability among the different sources. The benefit measure was appropriate as it captured the most relevant dimension of health and will allow cross-disease comparisons to be made. Appropriate discounting was applied, in accordance with international guidelines.
The cost categories were consistent with the economic viewpoint of the study. Extensive details on the calculation of the lifetime health care costs for HIV-infected children were provided in an appendix. The sources of data were reported as well as other assumptions required for the calculation of the long-term costs. The price year and the use of discounting were reported. In general, the economic analysis was extensively presented.
Analysis and results:
The costs and benefits were synthesised in an incremental approach, which was appropriate for identifying the optimal strategy. The issue of uncertainty was addressed using a partial approach, which considered the variability of model inputs one at a time. A more comprehensive approach would have been more appropriate, but the results of the study were robust even under conditions that favoured no screening. The authors compared their results with those from other studies, which showed that these findings were generally more favourable for antenatal HIV-screening.
On the whole, the study was well conducted and satisfactorily presented, but more details on the clinical sources would have been useful. The authors’ conclusions appear to be robust and valid.
Rozenbaum MH, Verweel G, Folkerts DK, Dronkers F, van den Hoek JA, Hartwig NG, de Groot R, Postma MJ. Cost-effectiveness estimates for antenatal HIV testing in the Netherlands. International Journal of STD and AIDS 2008; 19(10): 668-675
Other publications of related interest
Bos JM, Fennema JS, Postma MJ. Cost-effectiveness of HIV screening of patients attending clinics for sexually transmitted diseases in Amsterdam. AIDS 2001; 15: 2031-2036.
Coco A. The cost-effectiveness of expanded testing for primary HIV infection. Annals of Family Medicine 2005; 3: 391-399.
Graves N, Walker DG, McDonald AM, Kaldor JM, Ziegler JB. Would universal antenatal screening for HIV infection be cost-effective in a setting of very low prevalence? Modelling the data for Australia. Journal of Infectious Diseases 2004; 190: 166-174.
Bramley D, Graves N, Walker D. The cost effectiveness of universal antenatal screening for HIV in New Zealand. AIDS 2003; 17: 741-748.
Sax PE, Islam R, Walensky RP, et al. Should resistance testing be performed for treatment naive HIV-infected patients? A cost-effectiveness analysis. Clinical Infectious Diseases 2005; 41: 1316-1323.
Subject indexing assigned by NLM
AIDS Serodiagnosis /economics; Adult; Antiretroviral Therapy, Highly Active /economics; Cost of Illness; Cost-Benefit Analysis; Female; HIV Infections /diagnosis /drug therapy /economics; Health Care Costs; Humans; Infant, Newborn; Infectious Disease Transmission, Vertical /economics /prevention & Mass Screening /economics; Netherlands; Pregnancy; Pregnancy Complications, Infectious /diagnosis /epidemiology /virology; Quality-Adjusted Life Years; control
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Date abstract record published