Economic evaluation of an alternative drug to sulfadoxine-pyrimethamine as intermittent preventive treatment of malaria in pregnancy.
BACKGROUND
Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended in HIV-negative women to avert malaria, while this relies on cotrimoxazole prophylaxis (CTXp) in HIV-positive women. Alternative antimalarials are required in areas where parasite resistance to antifolate drugs is high. The cost-effectiveness of IPTp with alternative drugs is needed to inform policy.


METHODS
The cost-effectiveness of 2-dose IPTp-mefloquine (MQ) was compared with IPTp-SP in HIV-negative women (Benin, Gabon, Mozambique and Tanzania). In HIV-positive women the cost-effectiveness of 3-dose IPTp-MQ added to CTXp was compared with CTXp alone (Kenya, Mozambique and Tanzania). The outcomes used were maternal clinical malaria, anaemia at delivery and non-obstetric hospital admissions. The poor tolerability to MQ was included as the value of women's loss of working days. Incremental cost-effectiveness ratios (ICERs) were calculated and threshold analysis undertaken.


RESULTS
For HIV-negative women, the ICER for IPTp-MQ versus IPTp-SP was 136.30 US$ (2012 US$) (95%CI 131.41; 141.18) per disability-adjusted life-year (DALY) averted, or 237.78 US$ (95%CI 230.99; 244.57), depending on whether estimates from Gabon were included or not. For HIV-positive women, the ICER per DALY averted for IPTp-MQ added to CTXp, versus CTXp alone was 6.96 US$ (95%CI 4.22; 9.70). In HIV-negative women, moderate shifts of variables such as malaria incidence, drug cost, and IPTp efficacy increased the ICERs above the cost-effectiveness threshold. In HIV-positive women the intervention remained cost-effective for a substantial (up to 21 times) increase in cost per tablet.


CONCLUSIONS
Addition of IPTp with an effective antimalarial to CTXp was very cost-effective in HIV-positive women. IPTp with an efficacious antimalarial was more cost-effective than IPTp-SP in HIV-negative women. However, the poor tolerability of MQ does not favour its use as IPTp. Regardless of HIV status, prevention of malaria in pregnancy with a highly efficacious, well tolerated antimalarial would be cost-effective despite its high price.


BACKGROUND
ClinicalTrials.gov NCT 00811421; Pan African Trials Registry PACTR2010020001429343 and PACTR2010020001813440.
ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
Elisa
E
Sicuri
London School of Hygiene and Tropical Medicine, London, United Kingdom.
Silke
S
Fernandes
Manhiça Health Research Center (CISM), Manhiça, Mozambique.
Eusebio
E
Macete
ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Manhiça Health Research Center (CISM), Manhiça, Mozambique.
Raquel
R
González
Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany.
Ghyslain
G
Mombo-Ngoma
Faculté des Sciences de la Santé (FSS), Université d'Abomey Calavi, Cotonou, Benin.
Achille
A
Massougbodgi
Ifakara Health Institute, Dar Es Salaam, Tanzania.
Salim
S
Abdulla
Ifakara Health Institute, Dar Es Salaam, Tanzania.
August
A
Kuwawenaruwa
Kenya Medical Research Institute (KEMRI)/Center for Global Health Research, Kisumu, Kenya.
Abraham
A
Katana
Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA and Kisumu, Kenya.
Meghna
M
Desai
Institut de Recherche pour le Développement (IRD), Paris, France; Université René Descartes, Paris, France.
Michel
M
Cot
Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany; Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria.
Michael
M
Ramharter
Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany.
Peter
P
Kremsner
Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA and Kisumu, Kenya.
Laurence
L
Slustker
ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Manhiça Health Research Center (CISM), Manhiça, Mozambique.
John
J
Aponte
London School of Hygiene and Tropical Medicine, London, United Kingdom.
Kara
K
Hanson
ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Manhiça Health Research Center (CISM), Manhiça, Mozambique.
Clara
C
Menéndez
D000962:Antimalarials / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D004338:Drug Combinations; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007630:Kenya; D008288:Malaria / Q000517:prevention & control*; D015767:Mefloquine / Q000191:economics* / Q000627:therapeutic use; D009073:Mozambique; D011247:Pregnancy; D015597:Pregnancy Complications, Parasitic / Q000517:prevention & control*; D011739:Pyrimethamine / Q000191:economics* / Q000627:therapeutic use; D013413:Sulfadoxine / Q000191:economics* / Q000627:therapeutic use; D013636:Tanzania; D016896:Treatment Outcome
D000962:Antimalarials; D004338:Drug Combinations; C001205:fanasil, pyrimethamine drug combination; D013413:Sulfadoxine; D015767:Mefloquine; D011739:Pyrimethamine