Date of Award

January 2013

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

A D. Paltiel

Abstract

Background: Mother-to-child transmission (MTCT) of HIV continues to fuel the the HIV epidemic in resource-limited countries, especially in sub-Saharan Africa. To minimize MTCT, the World Health Organization (WHO) recommends a range of therapy guidelines - including Options B and B-Plus. Option B indicates that HIV-positive pregnant women in developing countries who are early in disease progression receive antiretroviral therapy (ART) during pregnancy and breastfeeding. An enhanced therapy recommendation, Option B-Plus, advises that all HIV-positive pregnant women initiate lifetime ART during their first pregnancy, regardless of disease progression. This study seeks to compare health outcomes and cost-effectiveness of adopting Option B-Plus versus Option B in Ghana.

Methods: A retrospective review of 817 medical records of HIV-infected women treated at two hospitals in Kumasi, Ghana was performed to obtain clinical values, including baseline CD4 count, fertility rate, and timing of antenatal care access, that were used in analysis. Using additional data from published literature, including changes in CD4 count and HIV-related costs, a decision-analytic model was developed to estimate quality-adjusted life expectancy for mothers and all future children following Option B-Plus or Option B. The model captures the probability of MTCT prenatally and during breastfeeding, both in the current and future pregnancies. Additional ART and healthcare cost calculations were performed to compare the cost-effectiveness of the regimens. Sensitivity analyses on model parameters were performed. Outcome values were evaluated against WHO benchmarks for cost-effectiveness.

Results: The average age at first pregnancy was 22.8 years (SD 5.0) and women had an average of 2.3 children (SD 1.3). Option B costs 6,038 USD over a woman's lifetime and yields 9.8 quality-adjusted life years (QALYs) to the mother and 62.2 QALYs to each child. Option B-Plus costs 16,727 USD and yields 16.3 QALYs to the mother and 67.6 QALYs to each child. Compared to Option B, Option B-Plus costs 625 USD per QALY gained, which would be considered "very cost-effective" by WHO benchmarks. If implemented on a national level, Option B-Plus could prevent nearly 1,000 HIV infections among children in Ghana each year, compared to Option B.

Results: Option B-Plus substantially reduces MTCT in current and future pregnancies, and is a very cost-effective use of limited resources. This cost-effectiveness remained over robust sensitivity analyses. Further, Option B-Plus demonstrates a substantial increase in both maternal and children QALYs. We recommend the implementation of policies supporting Option B-Plus in Ghana and other resource-limited countries affected by HIV.

Comments

This is an Open Access Thesis.

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