Cost-Effectiveness of Interventions to Reduce Vertical HIV Transmission from Pregnant Women Who Have Not Received Prenatal Care

To evaluate the cost-effectiveness of rapid HIV testing followed by treatmentwith zidovudine, nevirapine, or combination therapy for women presenting in the United States in active labor without prenatal care, the authors developed a decision analytic model from a societal perspective comparing 2 basic strategies: 1) not testing for HIV and 2) offering rapid HIV testing and treatment to women testing positive. HIV transmission rates, test characteristics, and costs were derived from the literature and local sources. Outcomes included number of infected infants, costs, and incremental cost-effectiveness in dollars per quality-adjusted life year saved. The authors found that offering rapid HIV testing and administering zidovudine treatment to women testing positive would prevent 27 cases of HIV each year and save $3,000,000/year compared with no intervention. If more expensive treatments were used (e.g., zidovudine rather than nevirapine, or combination therapy rather than monotherapy), the relative risk reduction in HIV transmission for the more expensive strategies would need to be only slightly better to make the more expensive strategies relatively costeffective in comparison with the less expensive strategies. In an analysis including empiric nevirapine prophylaxis, the authors found that empiric therapy would prevent 32 HIV cases and save $2.1million per year compared with no intervention. In conclusion, rapid HIV testing and treatment for women presenting in labor without prior prenatal care would prevent HIV infections and save costs. At sites where rapid HIV testing is not possible, empiric treatment would also prevent HIV infection and saves costs and is thus preferred to a strategy of neither testing nor treating. Effectiveness in reducing transmission drives the cost-effectiveness ratio much more so than drug cost and should be the basis on which a particular prophylactic regimen is selected.