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BackgroundNew WHO guidelines recommend initiation of antiretroviral therapy for HIV-positive adults with CD4 counts of 500 cells per μL or less, a higher threshold than was previously recommended. Country decision makers have to decide whether to further expand eligibility for antiretroviral therapy accordingly. We aimed to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy and expanded treatment coverage.MethodsWe used several independent mathematical models in four settings-South Africa (generalised epidemic, moderate antiretroviral therapy coverage), Zambia (generalised epidemic, high antiretroviral therapy coverage), India (concentrated epidemic, moderate antiretroviral therapy coverage), and Vietnam (concentrated epidemic, low antiretroviral therapy coverage)-to assess the potential health benefits, costs, and cost-effectiveness of various eligibility criteria for adult antiretroviral therapy under scenarios of existing and expanded treatment coverage, with results projected over 20 years. Analyses assessed the extension of eligibility to include individuals with CD4 counts of 500 cells per μL or less, or all HIV-positive adults, compared with the previous (2010) recommendation of initiation with CD4 counts of 350 cells per μL or less. We assessed costs from a health-system perspective, and calculated the incremental cost (in US$) per disability-adjusted life-year (DALY) averted to compare competing strategies. Strategies were regarded very cost effective if the cost per DALY averted was less than the country's 2012 per-head gross domestic product (GDP; South Africa: $8040; Zambia: $1425; India: $1489; Vietnam: $1407) and cost effective if the cost per DALY averted was less than three times the per-head GDP.FindingsIn South Africa, the cost per DALY averted of extending eligibility for antiretroviral therapy to adult patients with CD4 counts of 500 cells per μL or less ranged from $237 to $1691 per DALY averted compared with 2010 guidelines. In Zambia, expansion of eligibility to adults with a CD4 count threshold of 500 cells per μL ranged from improving health outcomes while reducing costs (ie, dominating the previous guidelines) to $749 per DALY averted. In both countries results were similar for expansion of eligibility to all HIV-positive adults, and when substantially expanded treatment coverage was assumed. Expansion of treatment coverage in the general population was also cost effective. In India, the cost for extending eligibility to all HIV-positive adults ranged from $131 to $241 per DALY averted, and in Vietnam extending eligibility to patients with CD4 counts of 500 cells per μL or less cost $290 per DALY averted. In concentrated epidemics, expanded access for key populations was also cost effective.InterpretationOur estimates suggest that earlier eligibility for antiretroviral therapy is very cost effective in low-income and middle-income settings, although these estimates should be revisited when more data become available. Scaling up antiretroviral therapy through earlier eligibility and expanded coverage should be considered alongside other high-priority health interventions competing for health budgets.FundingBill & Melinda Gates Foundation, WHO.

Objective To estimate the incremental cost over 5 years of a policy switch from the Option B to the Option B+ protocol for the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV). Methods Data from cost studies and other published sources were used to determine the cost, per woman and per cohort (1000 breastfeeding and 1000 non-breastfeeding women), of switching from Option B (maternal triple antiretroviral [ARV] regimen during pregnancy and breastfeeding plus daily nevirapine for the infant for 6 weeks) to Option B+ (maternal triple ARV regimen initiated during pregnancy and continued for life). The variables used to model the different scenarios were maternal CD4+ T lymphocyte (CD4+ cell) count (350-500 versus >500 cells/[micro]l), rate of decline in CD4+ cells (average, rapid, slow), breastfeeding status (yes, no) and breastfeeding duration (12, 18 or 24 months). Findings For women with CD4+ cell counts of 350-500 cells/pl, the incremental cost per 1000 women was 157 345 United States dollars (US$) for breastfeeding women and US$ 92 813 for non-breastfeeding women. For women with CD4+ cell counts > 500 cells/pl, the incremental cost per 1000 women ranged from US$ 363 443 to US$ 484591 for breastfeeding women and was US$ 605 739for non- breastfeeding women. Conclusion From a cost perspective, a policy switch from Option B to Option B+ is feasible in PMTCT programme settings where resources are currently being allocated to Option B. Objectif Estimer le surcout sur 5 ans d un changement de politique, avec le passage du protocole de l'Option B a celui de l'Option B+ dans le cadre de la prevention de la transmission de la mere a l'enfant (PTME) du virus de fimimunodefidence humaine (VIH). Methodes Des donnees issues d'etudes de couts et d'autres sources publlees ont ete utilisees pour determiner le cout, par femme et par cohorte (1000 femmes qui allaltent et 1000 femmes qui n'allaitent pas), du passage de l'Option B (traitement par tritherapie antiretrovirale [ARV] de la mere pendant la grossesse et l'allaitement, et administration quotidienne de nevirapine a l'enfant pendant 6 semaines) a l'Option B+ (traitement par tritherapie ARV initie pendant la grossesse et ensuite pris a vie). Les variables utilisees pour modeliser les differents scenarios ont ete la numeration des lymphocytes T CD4+ (cellules CD4+) chez la mere (350-500 contre > 500 cellules/[micro]l), la vitesse de la baisse des cellules CD4+ (moyenne, rapide, lente), la situation au regard de l'allaitement maternel (oui, non) et la duree de l'allaitement (12,18 ou 24 mois). Resultats Pour les femmes presentant une numeration des cellules CD4+ de 350-500 cellules/pl, le surcout pour 1000 femmes etait de 157 345 dollars pour les femmes qui allaitent et de 92 813 dollars pour les femmes qui n'allaitent pas. Pour les femmes presentant une numeration des cellules CD4+ > 500 cellules/[micro]l, le surcout pour 1000 femmes etait compris entre 363 443 dollars et 484 591 dollars pour les femmes qul allaitent et de 605 739 dollars pour les femmes qui n'allaitent pas. Conclusion En termes de couts, un changement de politique de l'Option B a l'Option B+ est possible dans le cadre du programme PTME ou les ressources sont actuellement affectees a l'Option B. Objetivo Estimar el coste adicional en 5 anos de un cambio en la politica del protocolo de la opcion B a la opcion B+ para la prevencion de la transmision de madre a hijo (PTMI) del virus de inmunodeficiencia humana (VIH). Metodos Se emplearon datos de estudios de costes y otras fuentes publicadas para determinar el coste, por mujer y por cohorte (1000 mujeres lactantesy 1000 mujeres no lactantes), al cambiar de la opcion B (regimen antirretroviral triple materno [ARV] durante el embarazo y la lactancia materna junto con nevlraplna diaria para el lactante durante 6 semanas) a la opcion B+ (regimen antirretroviral triple ARV Iniciado durante el embarazo y tomado de por vida). Las variables empleadas para modelar los diversos escenarios fueron el recuento de linfocitos (CD4+ celulas) CD4+ T maternos (350-500 frente a > 500 celulas/pl), la tasa de disminucion de CD4+ celulas (media, rapida, lenta), el estado de lactancia materna (si, no) y la duracion de la lactancia materna (12, 18 o 24 meses). Resultados En las mujeres con un recuento de CD4+ de 350-500 celulas/[micro]l, el coste adicional por 1000 mujeres fue 157 345 dolares de los Estados Unidos (US$) para las mujeres lactantes y US$ 92 813 para las mujeres no lactantes. En las mujeres con un recuento de CD4 + celulas de > 500 celulas/[micro]l, el coste adicional por 1000 mujeres vario de US$ 363 443 a US$ 484 591 en las mujeres lactantes y US$ 605 739 en las mujeres no lactantes. Conclusion Desde el punto de vista de los costes, un cambio en la politica de la B opcion a la opcion B+ es factible en la configuracion del programa de PTMI, en el que en la actualidad los recursos se estan destinando a la opcion B., Introduction In July 2011, a United Nations political declaration called for greater efforts to eliminate human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). It established commitments and targets, [...]

Ambitious goals for paediatric AIDS control have been set by various international bodies, including a 50% reduction in new paediatric infections by 2010. While these goals are clearly appropriate in their scope, the lack of clarity and consensus around how to monitor the effectiveness of programmes to prevent mother-to-child HIV transmission (PMTCT) makes it difficult for policy-makers to mount a coordinated response. In this paper, we develop the case for using population HIV-free child survival as a gold standard metric to measure the effectiveness of PMTCT programmes, and go on to consider multiple study designs anal source populations. Finally, we propose a novel community survey-based approach that could be implemented widely throughout the developing world with minor modifications to ongoing Demographic and Health Surveys. Resume Des objectifs ambitieux en matiere de lutte contre le VIH/sida en milieu pediatrique ont ete fixes par divers organismes internationaux, et notamment la reduction de moitie du nombre de nouveaux cas d'infection pediatrique d'ici 2010. Meme si ces objectifs sont tout a fait pertinents dans leur contexte, le manque de clarte et de consensus quant aux personnes devant surveiller I'efficacite des programmes de prevention de la transmission mere-enfant du VIH (PMTCT) s'oppose a I'obtention d'une reponse coordonnee de la part des decideurs. Cet article presente les arguments en faveur de I'utilisation du taux de survie des enfants sans contamination par le VIH dans la population comme instrument de mesure cle de I'efficacite des programmes de PMTCT et examine divers types d'etude et plusieurs populations sources. II propose en conclusion une approche novatrice, reposant sur des enquetes en communaute, qui pourrait etre mise en oeuvre a grande echelle dans le monde en developpement, moyennant I'apport de modifications mineures aux enquetes demographiques et sanitaires en cours. Resumen Diversos organos internacionales han fijado metas ambiciosas para la lucha contra el SIDA pediatrico, en particular una reduccion del 50% de las nuevas infecciones pediatricas para 2010. Aunque se trata de metas indudablemente acertadas en cuanto a su alcance, la falta de claridad y consenso respecto a la manera de vigilar la eficacia de los programas de prevencion de la transmision del VIH de la madre al nino (PTMN) es un obstaculo para que las instancias normativas articulen una respuesta coordinada. Se aportan aqui argumentos para utilizar la supervivencia infantil sin infeccion por VIH en la poblacion como criterio de referencia para medir la eficacia de los programas de PTMN, y se examinan luego varios disenos de estudio y poblaciones de diverso origen. Por ultimo, proponemos un nuevo enfoque basado en encuestas comunitarias que podria implementarse ampliamente en todo el mundo en desarrollo introduciendo pequenos cambios en las actuales Encuestas de Demografia y Salud. [TEXT NOT REPRODUCIBLE IN ASCII.], Introduction Despite the availability of proven interventions for the prevention of mother-to-child HIV transmission (PMTCT) and substantial donor investments for implementing them in developing countries, paediatric AIDS remains a largely [...]

The impact of the introduction of routine opt-out HIV testing in antenatal care in Botswana is examined. The results have shown that routine HIV testing is more accepted than voluntary testing and it has led to substantial increases in the uptake of testing and prevention of mother-to-child transmission (PMTCT) interventions without adverse consequences.

Introduction: HIV testing is the entry point for the elimination of mother-to-child transmission of HIV. Decreasing external funding for the HIV response in some low- and middle-income countries has triggered the question of whether a focused approach to HIV testing targeting pregnant women in high-burden areas should be considered. This study aimed at determining and comparing the cost-effectiveness of universal and focused HIV testing approaches for pregnant women across high to very low HIV prevalence settings. Methods: We conducted a modelling analysis on health and cost outcomes of HIV testing for pregnant women using four country-based case scenarios (Namibia, Kenya, Haiti and Viet Nam) to illustrate high, intermediate, low and very low HIV prevalence settings. We used subnational prevalence data to divide each country into high-, medium- and low-burden areas, and modelled different antenatal and testing coverage in each. Results: When HIV testing services were only focused in high-burden areas within a country, mother-to-child transmission rates remained high ranging from 18 to 23%, resulting in a 25 to 69% increase in new paediatric HIV infections and increased future treatment costs for children. Universal HIV testing was found to be dominant (i.e. more QALYs gained with less cost) compared to focused approaches in the Namibia, Kenya and Haiti scenarios. The universal approach was also very cost-effective compared to focused approaches, with $ 125 per quality-adjusted life years gained in the Viet Nam-based scenario of very low HIV prevalence. Sensitivity analysis further supported the findings. Conclusions: Universal approach to antenatal HIV testing achieves the best health outcomes and is cost-saving or cost-effective in the long term across the range of HIV prevalence settings. It is further a prerequisite for quality maternal and child healthcare and for the elimination of mother-to-child transmission of HIV. Keywords: HIV; mother-to-child transmission; HIV testing; cost-effectiveness; universal approach; focused approach., Introduction The prevention of mother-to-child transmission (PMTCT) of HIV by providing antiretroviral therapy (ART) to HIV-positive pregnant women is a highly effective intervention to prevent new HIV infections among infants. [...]

At present, HIV testing and counselling during pregnancy represent the key entry point for women to learn their serostatus and for them to access, if they are HIV-positive, specific interventions to reduce mother-to-child transmission (MTCT) of HIV. However, the provision and uptake of testing and counselling services are inadequate, and many pregnant women in countries most affected by the HIV/AIDS epidemic remain unaware of their HIV status. The offer of single-dose nevirapine prophylaxis to women whose HIV status is unknown at the time of delivery has been proposed to circumvent these problems in high-prevalence settings. The potential advantages and disadvantages of three different programme approaches are considered: targeted programmes in which antiretroviral drugs are offered only to women who are known to be HIV-positive; combined programmes in which nevirapine prophylaxis is offered to women whose serostatus remains unknown at the time of delivery despite targeted programme inputs; and universal nevirapine prophylaxis programmes in which HIV testing and counselling are not available and all pregnant women, regardless of their serostatus, are offered nevirapine prophylaxis. Keywords Nevirapine/therapeutic use; HIV infections/prevention and control; Disease transmission, Vertical/prevention and control; Health status; Pregnancy; Risk assessment (source: MESH, NLM). Mots cles Nevirapine/usage therapeutique; Infection a VIH/prevention et controle; Transmission verticale maladie/prevention et controle; Etat sanitaire; Grossesse; Evaluation risque (source : MESH, INSERM). Palabras clave Nevirapina/uso terapeutico; Infecciones por VIH/prevencion y control; Transmision vertical de enfermedad/prevencion y control; Estado de salud; Embarazo; Medicion de riesgo (fuente: DeCS, BIREME). [TEXT NOT REPRODUCIBLE IN ASCII.], Resume Devrait-on faire appel a la nevirapine pour prevenir la transmission mere-enfant du VIH dans le cas des femmes dont le statut serologique est inconnu ? Actuellement, le depistage du [...]

Research on methods for preventing HIV transmission from pregnant women to their babies in developing countries focuses on breastfeeding, the potential toxicity of AIDS drugs to the fetus, and the development of drug resistance on the part of the virus. Between 15% and 40% of pregnant women in eastern and southern Africa are HIV-positive.

Women who first test positive for HIV during their pregnancy are no more likely to transmit the virus to their baby than those who tested positive before their pregnancy. This was the conclusion of a study in Thailand before HIV-infected pregnant women were given AIDS drugs to prevent transmission.

A PCR assay to determine HIV-1 subtype E appears to be effective in detecting the virus in newborn babies of HIV-infected mothers. The test detected half of the babies who were infected at birth, and detected all infected babies at two and six months of age.

Background: Intrapartum and neonatal single-dose nevirapine (NVP) reduces the risk of mother-to-child HIV transmission but also induces viral resistance to non-nucleoside reverse transcriptase inhibitor (NNRTI) drugs. This drug resistance largely fades over time. We hypothesized that women with a prior single-dose NVP exposure would have no more than a 10% higher cumulative prevalence of failure of their NNRTI-containing antiretroviral therapy (ART) over the first 48 wk of therapy than would women without a prior exposure. Methods and Findings: We enrolled 355 NVP-exposed and 523 NVP-unexposed women at two sites in Zambia, one site in Kenya, and two sites in Thailand into a prospective, non-inferiority cohort study and followed them for 48 wk on ART. Those who died, discontinued NNRTI-containing ART, or had a plasma viral load ≥ 400 copies/ml at either the 24 wk or 48 wk study visits and confirmed on repeat testing were characterized as having failed therapy. Overall, 114 of 355 NVP- exposed women (32.1%) and 132 of 523 NVP-unexposed women (25.2%) met criteria for treatment failure. The difference in failure rates between the exposure groups was 6.9% (95% confidence interval [CI] 0.8%-13.0%). The failure rates of women stratified by our predefined exposure interval categories were as follows: 47 of 116 women in whom less than 6 mo elapsed between exposure and starting ART failed therapy (40%; p < 0.001 compared to unexposed women); 25 of 67 women in whom 7-12 mo elapsed between exposure and starting ART failed therapy (37%; p = 0.04 compared to unexposed women); and 42 of 172 women in whom more than 12 mo elapsed between exposure and starting ART failed therapy (24%; p = 0.82 compared to unexposed women). Locally weighted regression analysis also indicated a clear inverse relationship between virologic failure and the exposure interval. Conclusions: Prior exposure to single-dose NVP was associated with an increased risk of treatment failure; however, this risk seems largely confined to women with a more recent exposure. Women requiring ART within 12 mo of NVP exposure should not be prescribed an NNRTI-containing regimen as first-line therapy. Please see later in the article for the Editors' Summary., Introduction In many parts of the world, pediatric AIDS remains an uncontrolled epidemic [1]. The vast majority of children who become HIV infected acquire the virus from their mothers, either [...]

Data from the Joint United Nations Programme on HIV/AIDS (UNAIDS) indicate that in 2003, 34-46 million people were living with HIV infection, and three fourths of these cases were in [...]