Cost-effectiveness analysis of Option B+ for HIV prevention and treatment of mothers and children in Malawi

Abstract

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 250,000 maternal life years, as compared to mothers receiving only Option A or B, with savings of 153,000 and 172,000 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.

Figure 1. Abbreviated decision tree summarizing the analytical approach, policy options and results.

Figure 2. Cost effectiveness of various strategies for the prevention of new pediatric infections and the treatment of HIV-infected mothers in Malawi.

Current practice represents our base case scenario or the status quo in 2010. The next set of scenarios highlight the cost effectiveness of incrementally expanding program implementation and service delivery coverage, and ranges from PMTCT only to the addition of integrated ART-ANC services for eligible pregnant women, both identified immediately and at a later time. Universal coverage implies the availability of HIV services for mother and children at any point of needing treatment. Option B+ offers ART to pregnant women regardless of CD4 count.

Figure 3. Tornado diagram for the ICER of Option B+, base case is $455 per life year gained shown with the dotted line.