Health Economics Verification Of Interventions For The Prevention Of Mother-to-child Transmission Of HIV Infection

ObjectiveInterventions for the prevention of mother-to-child transmission of HIV(PMTCT)was an important part of AIDS prevention and therapy strategies in China.It included counseling and testing,antiretrovirus therapy(ART),antiretrovirus prophylaxis,safe delivery,reasonable feeding,infant early diagnoses and so on.Nowadays an obvious success has been made in Yunnan Province to prevent mother-to-child transmission of HIV infection.However under the background of combined anti-retroviral therapy(cART),HIV/AIDS has been transformed from a terminal illness into a chronic disease,it's critical to verify the PMTCT interventions by the health economics.The objectives of the study werei)to identify the method to construct health utility,an indicator in health economics to reflect the total health status and subjective satisfaction to their health conditions and also to explore the factors associated with the health utility under the PMTCT interventions.ii)to quantify the return on investment and to conduct a cost-effectiveness,cost-utility and cost-benefit analysis of Yunnan's PMTCT interventions from 2006 to 2015 from a health policymaker perspective to verify the cost-efficiency.iii)to conduct the decision-analytic models from the short-term and long-term respectively to simulate the clinical and economical outcomes of Option B+,an ART regimen in the PMTCT interventions,so as to determine the cost effective and applicability of Option B+ in Yunnan province.Methodsi)We Chose the investigation sites according to the HIV prevalence level of Yunnan Province.A retrospective cross-sectional survey was conducted in Yunnan Province's Maternal and Infant Health Care Hospital and Daguan,Yiliang(low prevalence level),Longling and Fengqing(moderate prevalence level)and Longchuan,Tengchong(high prevalence level)counties' Maternal and Infant Health Care Hospitals between April and June 2016.We defined respondents as pregnant women living with HIV.Demographic data and HIV infection-related data were collected through questionnaires designed by the study's staff.Health utility information was collected using two generic questionnaires:EQ-5D(EuroQoL 5-dimensions)and SF-12(12-item Short Form Health Survey).Social support was measured by SSRS(Social Support Rate Scale).After scoring,we determined the property of EQ-5D and used multivariable linear regression model to investigate the associated factors.ii)We conducted an ecological study using routinely collected surveillance data.Analysis was conducted from the perspective of the health policymaker.Information on the investment in Yunnan's PMTCT interventions was obtained from the Yunnan AIDS Prevention Bureau.Outcomes of our study included paediatric HIV cases averted,quality adjusted life years(QALY)acquired and economic costs avoided.We calculated the total economic cost as the sum of direct and indirect costs.Direct costs were defined as life-long expenses associated with HIV/AIDS treatment.Indirect costs were equated to the value of productivity lost due to early HIV/AIDS-related illness or death.Finally,sensitivity analysis was conducted to examine the impact of changing in model assumptions.iii)Firstly,a decision tree model was conducted to simulate health outcomes of infants and also to estimate the clinical and health economics outcomes of Option B+in the PMTCT period.In the sensitivity analysis,we emphasized on the transmission rate of Option B/Option B+ and we also considered to include the life-time ART cost into the cost calculation.Secondly,a Markov decision model was conducted to simulate the health outcomes of pregnant women living with HIV and also to estimated the clinical and health economics outcomes of Option B+ in the period from ending the PMTCT interventions to ten years after transforming to the regular ART,while considered the serodiscordant partner infections averted.In the sensitivity analysis,we emphasized on the coverage rate and the time horizon.Whether Option B+ was cost effective according to the WHO criteria.Resultsi)There was a total of 101 pregnant women living with HIV.The relationship was stronger between the EQ-5D functional dimensions and the PCS-12 and between the EQ-5D anxiety/depression dimension and the MCS-12.The relationship between the less comparable dimensions and component scores were weaker.Respondents were divided according to the median SF-12 component scores.Those who scored at the median or lower PCS-12 and MCS-12 scores were classified as being in worse health while,those over the median were classified as being in better health.Pearson correlation analysis showed that the EQ-5D health utility scores were positively correlated with both SF-12 components scores,r=0.51(P=0.0001)for PCS-12 and r=0.52(P =0.0001)for MCS-12.The VAS scores were also positively correlated with both SF-12 component scores,r=0.24(P =0.01)for PCS-12 and r=0.41(P =0.0001)for MCS-12.EQ-5D health utility and VAS scores were positively correlated(r=0.33,P=0.0001).The mean EQ-5D health utility score and EQ-VAS score of participants were 0.77(95%CI:0.74-0.79)and 75.77(95%CI:75.00-80.00)respectively.The effect of social support on health utility was maintained even after adjusting for the related factors.ii)The total investment increased from US$ 3.93 million in 2006,to US$ 5.46 million in 2015,a 38.93%increase over 10 years.we estimated that approximately 2,725 new infections were averted at an estimated US$ 18,044.71 investment required per infection averted.A total of 134,077.63 QALYs were acquired at an investment per QALY of US$ 366.67.After 2013,both the investment per infection averted and per QALY acquired were decreased.We estimated that Yunnan's PMTCT programmes saved US$ 0.49 billion-US$ 4.39 billion in direct costs(i.e.,treatment provided)and US$ 3.90 billion in indirect costs(i.e.,lost productivity).The total savings increased year by year.we found the Return on Investment(ROI)ratio was more than 45 every year and the total ROI ratio was 88.37 during the study period.The ROI also increased.iii)The cost-effectiveness analysis in short-term showed that Option B+ was with a cost-effectiveness ratio of 1156.63 for prevention new paediatric infection and of US$ 20.00 for QALY acquired.when compared to the Option A as the base case,the incremental cost-effectiveness ratios per QALY acquired were US$ 49.00 for Option B+,less than 1×GDP per capita of Yunnan province in 2016.The results of sensitivity analysis showed the cost per infection averted and per QALY acquired decreased by the efficacy increasing of Option B/B+ and Option B+ dominated the most-effective option when the lifetime ATR cost was included into the total cost.The cost-effectiveness analysis in long-term showed Option B+ resulted in a 10-year survival rate of 89.2%,the cost per life-year saved and per QALY acquired was US$ 1,660.69 and US$ 1,764.76,respectively.when we included the benefit to serodiscordant partners over 10 years,a cost per infection averted of US$ 7,655.70,and 3,068 infections were averted.In the sensitivity analysis,with the coverage rate of ART increasing to 90%,the ICER per life-year gained and ICER per QALY acquired compared to Option B were US$ 5,149.40 and US$ 5,319.36 respectively,less than 3×GDP per capita of Yunnan province in 2016.Otherwise,in 20-years horizon,the ICER per life-year gained and QALY acquired compared to Option B were US$3,568.22 and US$3,715.56 respectively,both less than 1×GDP per capita of Yunnan province in 2016.Conclusionsi)We could get the total health score by EQ-5D.It had a good applicability to evaluate the total health status for pregnant women living with HIV under the PMTCT interventions.The implementation of PMTCT improved the total health status of them to some extent and social support was a main factor associated with health utility,which demonstrated the importance to include the social support and care system into PMTCT interventions.ii)PMTCT interventions were cost-effective and cost-benefit in the periods from 2006 to 2015.Our results support the ongoing investment in PMTCT interventions in Yunnan Province.Especially in the periods from 2013 to 2015,the allocation of prevention resources was more efficiency.Despite required higher investments in the future,the overall investment in PMTCT intervention could be offset by averting more paediatric infections.When we achieve the goal of eliminating the transmission of HIV from mother-to-child during the 13th five-year plan,it will build a brighter future for the children,mothers,provinces and the nation.iii)Our study verified the advantage of Option B+ whatever in the period of prevention mother-to-child transmission of HIV and in regular ART period by combining the decision tree model and Markov decision model,especially by the goals of "90-90-90" and "95-95-95" achieved,the advantage of Option B+ would be more obvious.This study was not only to supply the reference for the ART regimen transferring in the PMTCT,but also to provide evidence for the applicability of Option B+ in Yunnan province.