title: Cost-effectiveness of routine rapid human immunodeficiency virus antibody testing before DNA-PCR testing for early diagnosis of infants in resource-limited settings.
abstract: BACKGROUND
  Infants born to HIV-infected women should receive HIV testing to allow early diagnosis and treatment. Recommendations for resource-limited settings stress laboratory-based virologic assays. While effective, these tests are logistically complex and expensive. This study explored the cost-effectiveness of incorporating initial screening with rapid HIV tests (RHT) into the conventional testing algorithm to screen-out HIV-uninfected infants, thereby reducing the need for costly virologic testing.
  
  
  METHODS
  Data on HIV prevalence, RHT sensitivity and specificity, and costs were collected from 820 HIV-exposed children (1.5-18 months) attending 2 postnatal screening programs in Uganda during July 2005 to December 2006. Cost-effectiveness models compared the conventional testing algorithm DNA polymerase chain reaction (DNA-PCR with Roche Amplicor v1.5) with a modified algorithm (initial RHT to screen-out HIV-uninfected infants before DNA-PCR).
  
  
  RESULTS
  The model estimated that the conventional algorithm would identify 94.3% (91.8%-94.7%) of HIV-infected infants, compared with 87.8% (79.4%-90.5%) for a modified algorithm using RHT (HIV 1/2 Determine) and excluding the need for DNA-PCR for HIV antibody-negative infants. Costs per infant were $23.47 ($23.32-$23.76) for the conventional algorithm and between $22.75 ($21.89-$23.31) and $7.58 ($6.41-$10.75) for the modified algorithm, depending on infant age and symptoms. Compared with the conventional algorithm, costs per HIV-infected infant identified using the modified algorithm were higher in 1.5-to 3-month-old infants, but significantly lower in 3-month-old and older infants. Models replicating the whole infant testing program showed the modified algorithm would have marginally lower sensitivity, but would reduce total program costs by 27% to 40%, producing an incremental cost-effectiveness ratio of $1489 ($686-$6781) for the conventional versus modified algorithms.
  
  
  CONCLUSIONS
  Screening infants with RHT before DNA-PCR is cost-effective in infants 3 months old or older. Incorporating RHT into early infant testing programs could improve cost-effectiveness and reduce program costs.
authors.affiliation: Centers for Disease Control and Prevention (CDC), Global AIDS Program, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, GA, USA. nmenzies@fas.harvard.edu
authors.forename: Nicolas A
authors.initials: NA
authors.lastname: Menzies
authors.forename: Jaco
authors.initials: J
authors.lastname: Homsy
authors.forename: Jeannie Y
authors.initials: JY
authors.lastname: Chang Pitter
authors.forename: Christian
authors.initials: C
authors.lastname: Pitter
authors.forename: Jonathan
authors.initials: J
authors.lastname: Mermin
authors.forename: Robert
authors.initials: R
authors.lastname: Downing
authors.forename: Thomas
authors.initials: T
authors.lastname: Finkbeiner
authors.forename: John
authors.initials: J
authors.lastname: Obonyo
authors.forename: Adeodata
authors.initials: A
authors.lastname: Kekitiinwa
authors.forename: Jordan
authors.initials: J
authors.lastname: Tappero
authors.forename: John M
authors.initials: JM
authors.lastname: Blandford
mesh_terms: D019411:Clinical Laboratory Techniques / Q000191:economics* / Q000379:methods; D004279:DNA, Viral / Q000235:genetics; D003906:Developing Countries; D042241:Early Diagnosis; D005260:Female; D015483:HIV Antibodies / Q000097:blood*; D015658:HIV Infections / Q000175:diagnosis* / Q000191:economics* / Q000453:epidemiology; D015497:HIV-1 / Q000235:genetics / Q000276:immunology / Q000302:isolation & purification*; D006280:Health Workforce; D006801:Humans; D007118:Immunoassay / Q000191:economics* / Q000379:methods; D007223:Infant; D008297:Male; D016133:Polymerase Chain Reaction / Q000191:economics* / Q000379:methods; D012680:Sensitivity and Specificity; D014454:Uganda / Q000453:epidemiology
chemical_list: D004279:DNA, Viral; D015483:HIV Antibodies