Cost-effectiveness of Routine Provider-Initiated Testing and Counseling for Children With Undiagnosed HIV in South Africa

Abstract

Background: We compared the cost-effectiveness of pediatric provider-initiated HIV testing and counseling (PITC) vs no PITC in a range of clinical care settings in South Africa.

Methods: We used the Cost-Effectiveness of Preventing AIDS Complications Pediatric model to simulate a cohort of children, aged 2-10 years, presenting for care in 4 settings (outpatient, malnutrition, inpatient, tuberculosis clinic) with varying prevalence of undiagnosed HIV (1.0%, 15.0%, 17.5%, 50.0%, respectively). We compared "PITC" (routine testing offered to all patients; 97% acceptance and 71% linkage to care after HIV diagnosis) with no PITC. Model outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs) from the health care system perspective and the proportion of children with HIV (CWH) diagnosed, on antiretroviral therapy (ART), and virally suppressed. We assumed a threshold of $3200/year of life saved (YLS) to determine cost-effectiveness. Sensitivity analyses varied the age distribution of children seeking care and costs for PITC, HIV care, and ART.

Results: PITC improved the proportion of CWH diagnosed (45.2% to 83.2%), on ART (40.8% to 80.4%), and virally suppressed (32.6% to 63.7%) at 1 year in all settings. PITC increased life expectancy by 0.1-0.7 years for children seeking care (including those with and without HIV). In all settings, the ICER of PITC vs no PITC was very similar, ranging from $710 to $1240/YLS. PITC remained cost-effective unless undiagnosed HIV prevalence was <0.2%.

Conclusions: Routine testing improves HIV clinical outcomes and is cost-effective in South Africa if the prevalence of undiagnosed HIV among children exceeds 0.2%. These findings support current recommendations for PITC in outpatient, inpatient, tuberculosis, and malnutrition clinical settings.

Keywords: HIV; PITC; cost-effectiveness; pediatric.

Figure 1.

One-year cascade of HIV care in the base case and 2-way sensitivity analysis with varying PITC acceptance rate and linkage to care upon receiving positive test results. We used lower-bound values of 60% for test acceptance and 50% for linkage to care and an upper-bound value of 100% for both. The change of 38%, 41%, and 31% for children who know their status, are on ART, and are virally suppressed, respectively, represents the relative increase from the lowest to the highest value in the HIV care continuum. Abbreviations: ART, antiretroviral therapy; PITC, provider-initiated HIV testing and counseling.

Figure 2.

Effect of undiagnosed HIV prevalence on the ICER of the routine PITC strategy vs no PITC in the base case analysis. The blue arrows point to the values of undiagnosed HIV prevalence that correspond to specific clinical settings—1.0% prevalence in outpatient centers, 15.0% prevalence in malnutrition clinics, 17.5% prevalence in inpatient wards, and 50.0% prevalence in TB clinics. The data point labeled ICER = 0.5× GDP is the cost-effectiveness threshold. The data points labeled ICER > 1×GDP and ICER > 0.5×GDP represent the undiagnosed HIV prevalence values at which the ICER of the PITC strategy vs no PITC becomes greater than 1× or 0.5× of the GDP of South Africa, respectively. Abbreviations: GDP, gross domestic product; ICER, incremental cost-effectiveness ratio; PITC, provider-initiated HIV testing and counseling; TB, tuberculosis; YLS, years of life saved.

Figure 3.

Univariate sensitivity analyses examining the impact of variation in individual input parameters on the ICER of the routine PITC program vs no PITC in the outpatient setting. Key parameters varied in sensitivity analyses are shown on the left. Values in parentheses indicate the range examined (from the value leading to the lowest ICER to the value leading to the highest ICER). The vertical line between the blue and red bars indicates the base case ICER value in the outpatient setting ($1240/YLS). Blue bars indicate values of parameters at which the ICER is lower than in the base case, and red bars indicate values of parameters at which the ICER is higher than in the base case. Longer bars indicate parameters to which cost-effectiveness results were more sensitive. Abbreviations: ICER, incremental cost-effectiveness ratio; PITC, provider-initiated HIV testing and counseling; YLS, year of life saved.

Figure 4.

Effect of undiagnosed HIV prevalence on the ICER of the routine PITC program vs no PITC in a 3-way sensitivity analysis. Varying prevalence of HIV (0.1%–20%) is displayed on the x-axis, and the ICER corresponding to each prevalence value is displayed on the y-axis. PITC test costs are shown in the base case ($4.70) and in sensitivity analyses ($15 and $35). The blue line indicates base case values of HIV care and ART costs. Orange, gray, and yellow lines indicate HIV care and ART costs at 0.1×, 0.5×, and 2× of the base case values, respectively. Abbreviations: ART, antiretroviral therapy; ICER, incremental cost-effectiveness ratio; PITC, provider-initiated HIV testing and counseling; YLS, years of life saved.