Cost-effectiveness analysis of infant feeding strategies to prevent mother-to-child transmission of HIV in South Africa

  • Mandy Maredza
  • Melanie Y Bertram
  • Haroon Saloojee
  • Matthew F Chersich
  • Stephen M Tollman
  • Karen J Hofman

Abstract

D espite increasing availability of perinatal interventions to prevent mother-to-child transmission (MTCT) of HIV in South Africa, MTCT remains high due to breastfeeding. To inform policy decisions in the country, cost-effectiveness of alternative infant-feeding interventions was conducted. Mathematical modelling was used to simulate post-natal transmission and mortality due to infant feeding in a hypothetical cohort of 1 000 HIV-exposed infants. Lifetime costs to the health system were calculated for each strategy. Interventions compared with current practice were: increasing coverage of extended nevirapine prophylaxis (ENP) to infants from 30% (base case) to 60% without changing current feeding practices; actively supporting breastfeeding with ENP to infants for 12 months; and actively supporting exclusive formula (replacement) feeding for 6 months. HIV-free survival at 24 months and disability-adjusted life years (DALYs) averted were estimated for typical rural and certain urban settings. Base-case analysis revealed that expanding coverage of nevirapine prophylaxis with breastfeeding is cost-saving and improves HIV-free survival. Changing feeding practices is beneficial, depending on context. Breastfeeding is dominant (less costly, more effective) in rural settings, whilst formula feeding is a dominant strategy in urban settings. Cost-effectiveness was most sensitive to proportion of women on lifelong antiretroviral therapy (ART) and infant mortality rate (IMR). When >55% of women are on ART, breastfeeding dominates in the urban settings modelled, whilst formula feeding is cost-effective in rural settings when IMR ≤ 45/1000. The study concludes that strategies to support breastfeeding are essential. Strengthening health systems is critical to ensure optimal nevirapine delivery during breastfeeding. A case can be made for formula feeding or breastfeeding in HIV-infected women in specific contexts.

Keywords: breastfeeding, cost-effectiveness, extended nevirapine prophylaxis, formula feeding, prevention of mother-to-child-transmission, South Africa

African Journal of AIDS Research 2013, 12(3): 151–160

Author Biographies

Mandy Maredza
MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Parktown 2193, Johannesburg, South Africa
Melanie Y Bertram
MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Parktown 2193, Johannesburg, South Africa
Haroon Saloojee
Division of Community Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
Matthew F Chersich
Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; International Centre for Reproductive Health, Department of Obstetrics and Gynaecology, Ghent University, Belgium
Stephen M Tollman
MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Parktown 2193, Johannesburg, South Africa; Centre for Global Health Research, Umeå University, Umeå, Sweden; INDEPTH Network, Accra, Ghana
Karen J Hofman
MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Parktown 2193, Johannesburg, South Africa
Published
2013-12-12
Section
Articles

Journal Identifiers


eISSN: 1608-5906
print ISSN: 1727-9445