The cost-effectiveness of repeat HIV testing during pregnancy in a resource-limited setting

Objective: To estimate the cost-effectiveness of HIV screening strategies for the prevention of perinatal transmission in Uganda, a resource-limited country with high HIV prevalence and incidence. Study Design: We designed a decision analytic model from a health care system perspective to assess the vertical transmission rates and cost-effectiveness of 4 different HIV screening strategies in pregnancy: (1) rapid HIV antibody (Ab) test at initial visit (current standard of care), (2) strategy 1 + HIV RNA at initial visit (adds detection of acute HIV), (3) strategy 1 + repeat HIV Ab at delivery (adds detection of incident HIV), and (4) strategy 3 + HIV RNA at delivery (adds detection of acute HIV at delivery). Model estimates were derived from the literature and local sources, and life years saved were discounted at a rate of 3% per year. Based on World Health Organization guidelines, we defined our cost-effectiveness threshold as #3 times the gross domestic product per capita, which for Uganda was US$3300 in 2008. Results: Using base case estimates of 10% HIV prevalence among women entering prenatal care and 3% incidence during pregnancy, strategy 3 was incrementally the cost-effective option that led to the greatest total life years. Conclusions: Repeat rapid HIV Ab testing at the time of labor is a costeffective strategy even in a resource-limited setting such as Uganda.