1. Presented by: Caitlin Dugdale, MD
The cost-effectiveness of integrating maternal ART into maternal & child health (MCH) services during the postpartum period in South Africa
Presented by: Caitlin Dugdale, MD
Tamsin K. Phillips, MPH; Landon Myer, MBChB, PhD; Emily P. Hyle, MD, MSc; Kirsty Brittain, MPH; Kenneth A. Freedberg, MD, MSc; Lucy Cunnama;
Rochelle P. Walensky, MD, MPH; Allison Zerbe; Elaine J. Abrams, MD; Andrea L. Ciaranello, MD, MPH; and the MCH-ART trial team
Supported by NICHD (R01HD and R01HD074558), NIAID (R01AI058736, R37AI093269, and T32AI007433), NHLBI (K01HL123349), PEPFAR, the World Health Organization, the Elizabeth Glaser Pediatric AIDS Foundation, and the IMPAACT network

2. Disclosures
We have no conflicts of interest to declare

3. High rates of postpartum LTFU and non-adherence
Postpartum loss to follow up (LTFU) and ART non-adherence contribute to adverse maternal and pediatric outcomes and MTCT among breastfeeding infants
12 months after delivery: 25-30% LTFU
For those in care, 70% virologically suppressed
Transfer of care from antenatal MCH services to separate postpartum maternal ART and infant HIV and well-child care is a vulnerable time for LTFU
References: UNAIDS 2016, Nachega AIDS 2012, Kaplan AIDS 2008, Phillips JIAS 2014, Haas Lancet HIV 2016, Tenthani AIDS 2014, Myer HIV Med 2017, Myer CID 2016, Van Lettow JIAS 2014.

4. Strategies to Optimize ART Services for Maternal & Child Health
MCH-ART Trial Strategies:
Routine care:
Referral to separate maternal ART and infant HIV and well-child care postpartum
Integrated care:
Co-located maternal ART and infant care integrated into MCH platform through the end of breastfeeding
Maternal ART care
References: Myer CROI 2017.
Infant HIV/well-child care
Delivery
Delivery
Maternal ART and infant care in MCH

5. MCH-ART Trial Results Results of integrated care:
Improved maternal retention in care and viral suppression at 12 months
Longer breastfeeding duration
Low MTCT by 1 year, similar in both arms
References: Myer CROI 2017.

6. Objective
To use MCH-ART trial data to project the long-term clinical impact and cost-effectiveness of the integrated care intervention compared to routine care for postpartum mothers and infants in South Africa.

7. Cost-Effectiveness of Preventing AIDS Complications (CEPAC)
CEPAC-International and CEPAC-Pediatrics: Monte Carlo simulation models of adult and pediatric HIV
Simulated individuals from delivery through death
MTCT by breastfeeding status and ART use
HIV progression including VL and CD4
ART adherence, LTFU, and return to care
Uses inputs from published literature and clinical trials to project long-term clinical and economic outcomes for mothers and children
References: Walensky NEJM Ciaranello PLoS ONE 2013 & AIDS Francke JID 2016.

8. Model Methods
Cohort: Postpartum mothers living with HIV and their breastfed infants in South Africa
Strategies:
Routine care: separate maternal ART/infant care
Integrated care: co-located maternal ART/infant care in MCH services until end of breastfeeding
Model-based outcomes:
MTCT rates
Maternal and infant life expectancy
Per-person HIV-related health care costs

9. Cost-effectiveness analysis
Incremental cost-effectiveness ratio (ICER):
ICER <1x per-capita GDP/YLS considered “cost-effective”
“Cost-effective” = additional health benefit worth the additional cost
2016 South Africa per-capita GDP= $5,260/YLS
Additional resource use
Additional health benefit $
Year of life saved (YLS) in
Reference: IMF 2017

10. Key model inputs from MCH-ART Trial
Maternal parameters
Routine care
Integrated care
Age (mean, in years)
28.6
CD4 count <350 cells/µL before ART
49%
Time on ART at delivery (median, in mo.)
4.3
Retention in care at 1 year
71%
81%
HIV viral load <50 copies/mL at 1 year
66%
Pediatric parameters
Breastfeeding duration (mean, in mo.) 6 8
Economic parameters
Additional integrated care intervention cost for mother-infant pair
-----
$200

11. (HIV-infected and uninfected)
Results
Lifetime projections (undiscounted)
Pediatric
(HIV-infected and uninfected)
Maternal
MTCT
(%)
LE (years)
HIV-related costs/person ($)
LE from delivery (years)
HIV-related costs/ person from delivery ($)
Routine care
1.7
62.4
290
26.5
21,920
Integrated care
27.3
22,570
MTCT: mother to child transmission; LE: life expectancy. All costs reported in 2016 USD.
The ICER of integrated care compared to routine care was $1,050/YLS*
<20% South Africa per-capita GDP
Considered cost-effective *Costs and LE discounted at 3%.

12. Trade offs: Breastfeeding, MTCT, and infant survival
Integrated care led to:
Improved maternal viral suppression:
↓ Risk of MTCT
Longer breastfeeding:
↑ Risk of MTCT
↓ Non-AIDS mortality

13. BF 12m in both arms ICER = $990/YLS
Sensitivity analysis
BF 12m in both arms ICER = $990/YLS
Integrated care was increasingly cost-effective with longer durations of breastfeeding

14. Additional sensitivity analyses
Cost
Integrated care was cost-effective unless the intervention cost was >$2,360/mother-infant pair
Unlikely at ~12x estimated cost
Effectiveness
Integrated care remained cost-effective even if intervention impact on maternal retention and viral suppression reduced by 50%
50% effectiveness: ICER $1,310/YLS

15. Limitations Uncertainty in long-term projections
Limited data on maternal retention and adherence beyond a few years postpartum
Repeat pregnancies and their potential impact on maternal re-engagement not considered
Exact intervention costs not yet known
Detailed costing study of intervention pending*
Costs and cost-effectiveness outcomes specific to South Africa
*Lucy Cunnama and Edina Sinanovic, UCT

16. Conclusion
Co-located maternal ART and infant care, integrated into maternal and child health services through the end of breastfeeding, is a cost-effective strategy to optimize postpartum maternal and infant outcomes in South Africa

17. CEPAC-Pediatric Team: Elaine Abrams, Ingrid Bassett, Alex Bulteel,
Acknowledgements
CEPAC-Pediatric Team: Elaine Abrams, Ingrid Bassett, Alex Bulteel,
Andrea L. Ciaranello, Sophie Desmonde, Caitlin Dugdale, Lorna Dunning, Simone Frank, Emily P. Hyle, Taige Hou, Valeriane Leroy, Landon Myer,
Anne Neilan, Robert Parker, Kunjal Patel, Martina Penazzato, George Seage, Djora Soeteman, Milton Weinstein, Rochelle P. Walensky, Kenneth A. Freedberg
Supported by: Supported by NICHD (R01HD and R01HD074558), NIAID (R01AI058736, R37AI093269, and T32AI007433), NHLBI (K01HL123349), PEPFAR, the World Health Organization, the Elizabeth Glaser Pediatric AIDS Foundation, and the IMPAACT network