title: Point-of-care CD4 testing to inform selection of antiretroviral medications in south african antenatal clinics: a cost-effectiveness analysis.
abstract: BACKGROUND
  Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays.
  
  
  METHODS
  We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96%, result-return rate: 87%, cost: $14) and POC (test rate: 99%, result-return rate: 95%, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO "Option A"): antenatal zidovudine (CD4 ≤350/μL) or ART (CD4>350/μL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/life-year saved).
  
  
  RESULTS
  In the base case, laboratory led to projected MTCT risks of 5.7%, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs.
  
  
  CONCLUSIONS
  In antenatal clinics implementing Option A, the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Ciaranello
authors.affiliation: School of Public Health and Family Medicine, Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa.
authors.forename: Landon
authors.initials: L
authors.lastname: Myer
authors.affiliation: General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Kelly
authors.affiliation: General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Sarah
authors.initials: S
authors.lastname: Christensen
authors.affiliation: School of Public Health and Family Medicine, Division of Epidemiology and Biostatistics, University of Cape Town, Cape Town, South Africa.
authors.forename: Kristen
authors.initials: K
authors.lastname: Daskilewicz
authors.affiliation: General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Katie
authors.initials: K
authors.lastname: Doherty
authors.affiliation: Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
authors.affiliation: General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Taige
authors.initials: T
authors.lastname: Hou
authors.affiliation: Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
authors.affiliation: General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Jordan A
authors.initials: JA
authors.lastname: Francke
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Illinois, United States of America.
authors.forename: Kara
authors.initials: K
authors.lastname: Wools-Kaloustian
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America; Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America; Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America.
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count / Q000191:economics* / Q000379:methods; D002648:Child; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics / Q000635:transmission; D017048:Health Care Costs; D006801:Humans; D007223:Infant; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008017:Life Expectancy; D019095:Point-of-Care Systems / Q000191:economics*; D011247:Pregnancy; D013019:South Africa; D055815:Young Adult; D015215:Zidovudine / Q000191:economics / Q000627:therapeutic use
chemical_list: D019380:Anti-HIV Agents; D015215:Zidovudine