title: Clinical Impact and Cost-effectiveness of Diagnosing HIV Infection During Early Infancy in South Africa: Test Timing and Frequency.
abstract: BACKGROUND
  Diagnosis of human immunodeficiency virus (HIV) infection during early infancy (commonly known as "early infant HIV diagnosis" [EID]) followed by prompt initiation of antiretroviral therapy dramatically reduces mortality. EID testing is recommended at 6 weeks of age, but many infant infections are missed.
  
  
  METHODS
  We simulated 4 EID testing strategies for HIV-exposed infants in South Africa: no EID (diagnosis only after illness; hereafter, "no EID"), testing once (at birth alone or at 6 weeks of age alone; hereafter, "birth alone" and "6 weeks alone," respectively), and testing twice (at birth and 6 weeks of age; hereafter "birth and 6 weeks"). We calculated incremental cost-effectiveness ratios (ICERs), using discounted costs and life expectancies for all HIV-exposed (infected and uninfected) infants.
  
  
  RESULTS
  In the base case (guideline-concordant care), the no EID strategy produced a life expectancy of 21.1 years (in the HIV-infected group) and 61.1 years (in the HIV-exposed group); lifetime cost averaged $1430/HIV-exposed infant. The birth and 6 weeks strategy maximized life expectancy (26.5 years in the HIV-infected group and 61.4 years in the HIV-exposed group), costing $1840/infant tested. The ICER of the 6 weeks alone strategy versus the no EID strategy was $1250/year of life saved (19% of South Africa's per capita gross domestic product); the ICER for the birth and 6 weeks strategy versus the 6 weeks alone strategy was $2900/year of life saved (45% of South Africa's per capita gross domestic product). Increasing the proportion of caregivers who receive test results and the linkage of HIV-positive infants to antiretroviral therapy with the 6 weeks alone strategy improved survival more than adding a second test.
  
  
  CONCLUSIONS
  EID at birth and 6 weeks improves outcomes and is cost-effective, compared with EID at 6 weeks alone. If scale-up costs are comparable, programs should add birth testing after strengthening 6-week testing programs.
authors.affiliation: Division of General Internal Medicine.|Medical Practice Evaluation Center.
authors.forename: Jordan A
authors.initials: JA
authors.lastname: Francke
authors.affiliation: Medical Research Council Clinical Trials Unit London, United Kingdom.|World Health Organization, Geneva, Switzerland.
authors.forename: Martina
authors.initials: M
authors.lastname: Penazzato
authors.affiliation: Division of General Internal Medicine.|Medical Practice Evaluation Center.
authors.forename: Taige
authors.initials: T
authors.lastname: Hou
authors.affiliation: International Center for AIDS Care and Treatment Program, Mailman School of Public Health.|College of Physicians and Surgeons, Columbia University, New York.
authors.forename: Elaine J
authors.initials: EJ
authors.lastname: Abrams
authors.affiliation: Division of General Internal Medicine.|Medical Practice Evaluation Center.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: MacLean
authors.affiliation: Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa.
authors.forename: Landon
authors.initials: L
authors.lastname: Myer
authors.affiliation: Division of General Internal Medicine.|Medical Practice Evaluation Center.|Division of Infectious Diseases, Department of Medicine.|Division of Infectious Diseases, Brigham and Women's Hospital.|Center for AIDS Research, Harvard University.
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.affiliation: Inserm U1027, University of Toulouse 3, France.
authors.forename: Valériane
authors.initials: V
authors.lastname: Leroy
authors.affiliation: Department of Health Policy and Management, Harvard T. H. Chan School of Public Health.|Harvard Medical School, Boston, Massachusetts.
authors.forename: Milton C
authors.initials: MC
authors.lastname: Weinstein
authors.affiliation: Division of General Internal Medicine.|Medical Practice Evaluation Center.|Biostatistics Center, Massachusetts General Hospital.|Center for AIDS Research, Harvard University.|Harvard Medical School, Boston, Massachusetts.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Parker
authors.affiliation: Division of General Internal Medicine.|Medical Practice Evaluation Center.|Division of Infectious Diseases, Department of Medicine.|Center for AIDS Research, Harvard University.|Department of Health Policy and Management, Harvard T. H. Chan School of Public Health.
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.affiliation: Medical Practice Evaluation Center.|Division of Infectious Diseases, Department of Medicine.
authors.forename: Andrea
authors.initials: A
authors.lastname: Ciaranello
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D042241:Early Diagnosis; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000191:economics*; D017048:Health Care Costs; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D013019:South Africa; D055815:Young Adult
keywords: birth testing; cost-effectiveness; early infant HIV diagnosis; human immunodeficiency virus; nucleic acid test