title: Cost-effectiveness of HIV and syphilis antenatal screening: a modelling study.
abstract: The WHO called for the elimination of maternal-to-child transmission (MTCT) of HIV and syphilis, a harmonised approach for the improvement of health outcomes for mothers and children. Testing early in pregnancy, treating seropositive pregnant women and preventing syphilis reinfection can prevent MTCT of HIV and syphilis. We assessed the health and economic outcomes of a dual testing strategy in a simulated cohort of 100 000 antenatal care patients in Malawi.
  
  
  
  We compared four screening algorithms: (1) HIV rapid test only, (2) dual HIV and syphilis rapid tests, (3) single rapid tests for HIV and syphilis and (4) HIV rapid and syphilis laboratory tests. We calculated the expected number of adverse pregnancy outcomes, the expected costs and the expected newborn disability-adjusted life years (DALYs) for each screening algorithm. The estimated costs and DALYs for each screening algorithm were assessed from a societal perspective using Markov progression models. Additionally, we conducted a Monte Carlo multiway sensitivity analysis, allowing for ranges of inputs.
  
  
  
  Our cohort decision model predicted the lowest number of adverse pregnancy outcomes in the dual HIV and syphilis rapid test strategy. Additionally, from the societal perspective, the costs of prevention and care using a dual HIV and syphilis rapid testing strategy was both the least costly ($226.92 per pregnancy) and resulted in the fewest DALYs (116 639) per 100 000 pregnancies. In the Monte Carlo simulation the dual HIV and syphilis algorithm was always cost saving and almost always reduced DALYs compared with HIV testing alone.
  
  
  
  The results of the cost-effectiveness analysis showed that a dual HIV and syphilis test was cost saving compared with all other screening strategies. Updating existing prevention of mother-to-child HIV transmission programmes in Malawi and similar countries to include dual rapid testing for HIV and syphilis is likely to be advantageous.
authors.affiliation: Division of Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA.
authors.forename: Claire C
authors.initials: CC
authors.lastname: Bristow
authors.affiliation: Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.
authors.forename: Elysia
authors.initials: E
authors.lastname: Larson
authors.affiliation: Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA.
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Anderson
authors.affiliation: Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA Division of Infectious Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA.
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Klausner
mesh_terms: D000328:Adult; D000465:Algorithms; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000191:economics / Q000517:prevention & control / Q000635:transmission; D006801:Humans; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000191:economics / Q000517:prevention & control*; D008295:Malawi; D008403:Mass Screening / Q000191:economics*; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis* / Q000191:economics / Q000517:prevention & control; D011256:Pregnancy Outcome; D011295:Prenatal Care / Q000191:economics*; D011296:Prenatal Diagnosis / Q000191:economics*; D011933:Reagent Kits, Diagnostic / Q000191:economics; D013587:Syphilis / Q000175:diagnosis* / Q000191:economics / Q000517:prevention & control / Q000635:transmission
chemical_list: D011933:Reagent Kits, Diagnostic
keywords: COST-EFFECTIVENESS; DIAGNOSIS; HIV; HIV TESTING; SYPHILIS