Rapid HIV versus enzyme-linked immunosorbent assay screening in a low-risk Mexican American population presenting in labor: a cost-effectiveness analysis.
OBJECTIVE
Mother-to-child transmission of human immunodeficiency virus is the most common cause of pediatric human immunodeficiency virus in the United States; the Centers for Disease Control and Prevention recommendations endorse rapid human immunodeficiency virus testing for women with unknown viral status to quicken antiretroviral therapy. We compared the cost-effectiveness of Oraquick (Orasure Technologies, Bethlehem, Pa) rapid testing versus enzyme-linked immunosorbent assay testing for a low-risk population of Mexican American women who are in labor.


METHODS
Using decision analysis techniques, we tested 2 strategies: (1) testing with enzyme-linked immunosorbent assay that was confirmed by Western blot and (2) testing with Oraquick rapid testing that was confirmed by Western blot. All seropositive parturients received zidovudine treatment in labor. The baseline assumptions were the incidence of human immunodeficiency virus in Mexican American mothers (0.05%), mother-to-child transmission with no treatment (25%), with treatment in labor (10%), sensitivity of enzyme-linked immunosorbent assay (98%), positive predictive value of enzyme-linked immunosorbent assay (10%), sensitivity/specificity of Oraquick rapid testing (99%/100%), positive predictive value of Oraquick rapid testing (83%-100%), sensitivity/specificity of Western blot (97%/99%), costs (enzyme-linked immunosorbent assay [dollar 5], Oraquick rapid testing [dollar 15], Western blot [dollar 25], zidovudine treatment [dollar 76] for 12 hours labor, neonatal treatment [dollar 2.50], lifetime treatment of human immunodeficiency virus-affected child [dollar 194,250]). Sensitivity analyses were done over a wide range of assumptions that included the costs of tests, the sensitivity of Oraquick rapid testing, the positive predictive value of enzyme-linked immunosorbent assay and Oraquick rapid testing, and the costs of treatments.


RESULTS
Oraquick rapid testing was the preferred strategy at dollar 98 spent per human immunodeficiency virus-negative child versus dollar 491 for enzyme-linked immunosorbent assay testing. Much of the cost of the enzyme-linked immunosorbent assay strategy was due to the treatment of women and infants with false-positive tests. Sensitivity analysis over test costs, test sensitivity, and other variables found the analysis results to be robust. Threshold analysis revealed that, if the cost remained < dollar 409.90, Oraquick rapid testing was the dominant test.


CONCLUSIONS
In a low prevalence population, the universal use of Oraquick rapid testing is cost-effective because of the low rate of false-positive results, thus preventing the emotional and economic costs of unnecessary treatment for human immunodeficiency virus to the new mother and her family.
Doyle
Nora M
NM
Department of Obstetrics, Gynecology, and Reproductive Medicine, Division of Maternal-Fetal Medicine, University of Texas-Houston Health Science Center, USA. ndoyle@emory.edu
Levison
Judy E
JE
Gardner
Michael O
MO
D019380:Anti-HIV Agents / Q000627:therapeutic use; D015153:Blotting, Western; D003661:Decision Support Techniques; D004797:Enzyme-Linked Immunosorbent Assay / Q000191:economics*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis*; D006801:Humans; D007118:Immunoassay / Q000379:methods*; D007743:Labor, Obstetric; D008403:Mass Screening / Q000379:methods; D017058:Mexican Americans; D019095:Point-of-Care Systems; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis*; D012680:Sensitivity and Specificity; D013781:Texas; D015215:Zidovudine / Q000627:therapeutic use
D019380:Anti-HIV Agents; D015215:Zidovudine