The cost-effectiveness of point-of-care platforms for early infant diagnosis of

HIV infection in Southern Province, Zambia

Catherine Sutcliffe

Johns Hopkins Bloomberg School of Public Health

July 19, 2019

Disclosures

Institutional grant funding:Pfizer Inc.

Novavax Inc.

Bristol-Myers Squibb Company

Roche Molecular Systems Inc.

Background

Early infant diagnosis is challenging in resource-limited settings

Point-of-care tests have been developed that could increase access to testing and improve diagnosis and linkage to care

Sample

arrives at labSample collected

Sample

tested at lab

Test result

arrives at

clinic

Test result

returned to

caregiver

Objective

To evaluate the cost-effectiveness of point-of-care platforms for early infant diagnosis of HIV infection in Southern Province, Zambia

Methods

Model of Zambian testing guidelines:Birth, 6 weeks, 6 months of age

Model parameters/costs from data collection and literature

Time horizon: 1) 12 months for infants; 2) 5 years for program

Scale: Southern Province (7,500 infants tested annually)

Testing platforms included:Standard of care: Nucleic-acid testing at the central lab (3 devices)

Point-of-care (POC): GeneXpert IV & m-PIMA (40 devices)

Outcomes:Health:

ART initiation within 60 days

ART initiation by 12 months of age

Deaths averted

Incremental cost-effectiveness ratios (ICERs): Δ costs / Δ health outcome

Cost:Capital costsRecurrent costsTotal program costs

Methods

Testing algorithms

Standard of care: Lab 1 + Lab 2

POC 1 + POC 2 + Lab 1

POC 1

POC 1 + POC 2 + POC 3 POC 1 + Lab 1

Results: Health outcomes

Point-of-care testing dramatically improved health outcomes

11.8

43.7

25.6

80.684.5

5.8

77.982.3

6.6

0

10

20

30

40

50

60

70

80

90

ART initiation within 60 days ART initiation by 12 months HIV-related deaths

Perc

enta

ge

Lab m-PIMA Xpert

PMTCT coverage: 93% Number of children infected with HIV: 1,476

Results: Costs

0.130

0.839 0.898

0.130 0.157 0.123

2.748

3.520

2.039

2.748

3.520

2.039

2.878

4.377

2.947 2.878

3.678

2.162

0.000

0.500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

4.500

5.000

Lab m-PIMA Xpert Lab m-PIMA Xpert

USD

(m

illio

ns)

Capital costs Recurrent costs Column1

When only used for EID, POC testing had similar/higher costs than lab testing

Sharing capital costs across programs significantly reduced capital costs

Non-shared capital costs Shared capital costs

Recurrent cost per test: $38.07 for Lab, $48.28 for m-PIMA, $27.91 for GeneXpert

Results: ICERs

1460

61

2459

104

5088

211788

-736

1328

-1259

2748

-2569-3000

-2000

-1000

0

1000

2000

3000

4000

5000

6000

m-PIMA Xpert m-PIMA Xpert m-PIMA Xpert

USD

Non-shared Shared

Additional cost per additional child

initiated on ART within 60 days

Additional cost per additional child

initiated on ART by 12 months of age

Additional cost per death averted

Results

Factors decreasing cost-effectiveness of point-of-care platforms:Increased efficiency of centralized lab testing

Increased number of POC instruments

Shorter lifetime of POC instruments

Increased cost for training, infrastructure, and supervision

Note: All results should be interpreted in the context of the assumptions made in the model

Conclusions

Point-of-care platforms can significantly improve health outcomesMore rapid diagnosis and ART initiation

Decrease in HIV-related deaths prior to ART initiation

Point-of-care platforms have similar or higher costs compared to centralized lab testing if only used for early infant diagnosis

Costs can be significantly reduced if shared across programs

Point-of-care platforms should be considered for implementation to improve early infant diagnosis

Particularly in settings with low PMTCT coverage and where centralized testing is delayed

Acknowledgements

InvestigatorsGatien De Broucker (JHBSPH)Phil Salvatore (JHBSPH)Bill Moss (JHBSPH)Phil Thuma (MRT)Jane Mutanga (LCH)Simon Mutembo (MoH)

Macha TeamNkumbula MoyoSylvia MaungaYvonnie PhiriHappy KamathaThando MaungaKathy SinywimaanziMutinta HamahuwaPasswell MunachoongaFrancis HamangabaBornface MunsanjeJeridy MunsanjeMathias Muleka

Mapanza TeamBrian SinkalaChanda SinkalaMilimo MwiingaAginita Mweemba

Moboola TeamAngelina MuchinduCatherine M’Simuko

FundingThis study was supported by a grant from the National Institute of Allergy and Infectious Diseases (1R01AI116324)

Mangunza TeamReuben ChirwaGladys Mukando

Nalube TeamJessy KanamaniBoyd MunkombweMacha Hospital Team

Clivinah ChipakoBilly HachililoRachel MatoomanaKenneth MuchinduCliff Mwaanga