Abstract
Background
We compared cost-effectiveness of pediatric provider-initiated HIV testing and counseling (PITC) versus no PITC in a range of clinical care settings in South Africa.
Methods
We used the CEPAC-Pediatric model to simulate a cohort of children, aged 2-10 years, presenting for care in four settings (outpatient, malnutrition, inpatient, tuberculosis clinic) with varying prevalence of undiagnosed HIV (1.0%, 15.0%, 17.5%, 50.0%, respectively). We compared “PITC” (routine testing offered to all patients; 97% acceptance and 71% linkage to care after HIV diagnosis) to no PITC. Model outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs) from the healthcare system perspective, and the proportion of children living with HIV (CLWH) diagnosed, on ART, and virally suppressed. We assumed a threshold of $3,200/YLS to determine cost-effectiveness. Sensitivity analyses varied the age distribution of children seeking care and costs for PITC, HIV care, and ART.
Results
PITC improved the proportion of CLWH diagnosed (45.2% to 83.2%), on ART (40.8% to 80.4%), and virally suppressed (32.6% to 63.7%) at one year in all settings. PITC increased life expectancy by 0.1-0.7 years for children seeking care (including those with and without HIV). In all settings, the ICER of PITC versus no PITC was very similar, ranging from $710-1,240/YLS. PITC remained cost-effective unless undiagnosed HIV prevalence was <0.2%.
Conclusions
Routine testing improves HIV clinical outcomes and is cost-effective in South Africa, if prevalence of undiagnosed HIV among children exceeds 0.2%. These findings support current recommendations for PITC in outpatient, inpatient, tuberculosis, and malnutrition clinical settings.