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Andrew F. Auld, Omotayo Bolu, Tracy Creek, Mary Lou Lindegren,

Potential Impact and Cost-Effectiveness of the 2009 “Rapid Advice” PMTCT Guidelines — 15 Resource-Limited Countries, 2010. Presented by Andrew F. Auld MBChB. Andrew F. Auld, Omotayo Bolu, Tracy Creek, Mary Lou Lindegren, Emilia Rivadeneira, Helen Dale, Nalinee Sangrujee, Tedd Ellerbrock.

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Andrew F. Auld, Omotayo Bolu, Tracy Creek, Mary Lou Lindegren,

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  1. Potential Impact and Cost-Effectiveness of the 2009 “Rapid Advice” PMTCT Guidelines — 15 Resource-Limited Countries, 2010 Presented by Andrew F. Auld MBChB Andrew F. Auld, Omotayo Bolu, Tracy Creek, Mary Lou Lindegren, Emilia Rivadeneira, Helen Dale, Nalinee Sangrujee, Tedd Ellerbrock Global AIDS Program, Centers for Disease Control and Prevention (CDC), Atlanta, U.S.A

  2. Peri-natal HIV Transmission • Globally, 420,000 infants become HIV-infected annually • About 90% of infections occur in Africa • 60% during pregnancy/birth • 40% during breastfeeding • Antiretroviral drugs (ARVs) known to significantly reduce HIV transmission during pregnancy and birth • In 2009 ARVs proven effective during breastfeeding • Guidelines for the use of ARVs for prevention of mother-to-child transmission (PMTCT): • Last published in 2006 • Revised in 2009

  3. 2006 vs. 2009 WHO PMTCT Guidelines -ART-Ineligible Women Choosing to Breastfeed

  4. 2006 vs. 2009 WHO PMTCT Guidelines -ART-Ineligible Women Choosing to Breastfeed

  5. 2006 vs. 2009 WHO PMTCT Guidelines -ART-Ineligible Women Choosing to Breastfeed

  6. 2006 vs. 2009 WHO PMTCT Guidelines -ART-Ineligible Women Choosing to Breastfeed

  7. 2006 vs. 2009 WHO PMTCT Guidelines -ART-Ineligible Women Choosing to Breastfeed

  8. 2006 vs. 2009 WHO PMTCT Guidelines -ART-Ineligible Women Choosing to Breastfeed

  9. 2006 vs. 2009 WHO PMTCT Guidelines -ART-Ineligible Women Choosing to Breastfeed

  10. Earlier ART for HIV-Infected Pregnant Women • 2006 WHO Guidelines: • CD4 < 200/µL • CD4 < 350/µL with WHO stage III • All WHO stage IV eligible • 2009 WHO Guidelines: Earlier ART • CD4 < 350/µL • All WHO stage III/IV eligible

  11. Rationale & Objectives for Research • Rationale: • 2009 PMTCT guidelines, adopting options A or B for ART-ineligible women, equally effective for HIV prevention (WHO 2009) • Other criteria, e.g. cost-effectiveness, feasibility, are important • Objectives: • To estimate in 15 resource-limited countries: • the potential cost-effectiveness • the potential costs saved, through reduced need to treat HIV-infected children, if countries choose option A or option B

  12. 15 Focus Countries of the US President’s Emergency Plan for AIDS Relief Vietnam Haiti Guyana Ethiopia Uganda Kenya Rwanda Cote d’Ivoire Tanzania Nigeria Namibia Zambia Botswana Mozambique SouthAfrica

  13. Methods • Deterministic model: • Follow cohorts of HIV-infected pregnant women and exposed infants born in each of the 15 focus countries during 2010 • Three PMTCT scenarios: • Scenario “A”: 2009 Guidelines with option A for ART-ineligible women • Scenario “B”: 2009 Guidelines with option B for ART-ineligible women using the least expensive prophylactic regimen (AZT,3TC,EFV) • Scenario “2006”: 2006 WHO Guidelines

  14. Methods • To estimate cost-effectiveness of scenarios “A” & “B”, estimate: • Incremental cost-effectiveness ratios (ICERs) • Additional cost per additional life-years gained (LYG) of implementing either scenario “A” or “B” instead of the 2006 Guidelines • If ICER < Gross Domestic Product (GDP) / Capita: • Highly Cost-effective

  15. Methods • To estimate whether scenarios A & B are cost saving, estimate for each of the scenarios (“A”, “B”, and “2006”): • Total costs incurred by PMTCT program • Total lifetime treatment costs for infected children • If total costs for scenario A or B < total costs for scenario 2006: • Cost-saving

  16. Assumptions and Sensitivity Analysis • Key input parameters: • PMTCT effectiveness data: Kesho-Bora and Ban • ARV costs and service fees: ARV procurement agencies & costing surveys • Multivariate sensitivity analysis: • 10,000 trials of Monte Carlo simulation created 95% confidence intervals (CI)

  17. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  18. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  19. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  20. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  21. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  22. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  23. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  24. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  25. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  26. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  27. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  28. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  29. Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

  30. Average ICER of implementing Scenario “A” Instead of Scenario “2006” – 15 Focus Countries, 2010

  31. Average ICER of implementing Scenario “A” Instead of Scenario “2006” – 15 Focus Countries, 2010

  32. Average ICER of implementing Scenario “A” Instead of Scenario “2006” – 15 Focus Countries, 2010

  33. Average ICER of implementing Scenario “A” Instead of Scenario “2006” – 15 Focus Countries, 2010

  34. Country-Specific ICERs of Implementing Scenario “A” Instead of Scenario “2006” – 15 Focus Countries, 2010

  35. Country-Specific ICERs of Implementing Scenario “A” Instead of Scenario “2006” – 15 Focus Countries, 2010

  36. Country-Specific ICERs of Implementing Scenario “A” Instead of Scenario “2006” – 15 Focus Countries, 2010

  37. Country-Specific ICERs of Implementing Scenario “A” Instead of Scenario “2006” – 15 Focus Countries, 2010 Ethiopia ICER US $94 GDP per capita ~US $364

  38. Potential Cost Savings of Implementing PMTCT Scenario “A” Instead of the 2006 PMTCT Guidelines

  39. Potential Cost Savings of Implementing PMTCT Scenario “A” Instead of the 2006 PMTCT Guidelines

  40. Potential Cost Savings of Implementing PMTCT Scenario “A” Instead of the 2006 PMTCT Guidelines

  41. Potential Cost Savings of Implementing PMTCT Scenario “A” Instead of the 2006 PMTCT Guidelines

  42. Potential Cost Savings of Implementing PMTCT Scenario “A” Instead of the 2006 PMTCT Guidelines Total Cost Savings of US$ 18 million 95% CI (US$ 49 million in savings – US$ 68 million in additional expenditure)

  43. Limitations • In establishing 95% CIs, only those input parameters that affected the ICER were varied • Costs of ARVs are continually changing

  44. Public Health Implications • In 2010, in 15 PEPFAR focus countries, we estimate: • Implementing 2009 WHO Guidelines could nearly triple infections averted • Option “B” is significantly more expensive than option “A” • The 2009 WHO Guidelines with option “A” are: • highly cost effective • possibly cost-saving in 9 of 15 PEPFAR focus countries

  45. Public Health Implications • These findings support: • Rapid implementation of the 2009 WHO PMTCT Guidelines • Option “A” the most cost-effective option

  46. Co-authors Omotayo Bolu Tracy Creek Mary Lou Lindegren Emilia Rivadeneira Helen Dale Nalinee Sangrujee Tedd Ellerbrock Collaborators Ray Shiraishi Elliot Raizes David Bell Nick Menzies Prahbu Vimanaland John Blandford Acknowledgements

  47. Thank You! The findings of this presentation are those of the authors and do not necessarily represent the views of the US Centers for Disease Control and Prevention

  48. Mother-to-Child HIV-Infections among Exposed Children Born in 15 Focus Countries, 2010

  49. Life-Time Treatment Costs for Infected Children Associated with PMTCT Strategy – 15 Focus Countries, 2010

  50. Varying Costs and Effectiveness of PMTCT Scenario “A” to Assess Effect on ICER – Ethiopia, 2010

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