Cost-Effectiveness of Routine Rapid Human Immunodeficiency Virus Antibody Testing Before DNA-PCR Testing for Early Diagnosis of Infants in Resource-Limited Settings

Background: Infants born to HIV-infected women should receive HIV testing to allow early diagnosis and treatment. Recommendations for resource-limited settings stress laboratory-based virologic assays. While effective, these tests are logistically complex and expensive. This study explored the cost-effectiveness of incorporating initial screening with rapid HIV tests (RHT) into the conventional testing algorithm to screen-out HIV-uninfected infants, thereby reducing the need for costly virologic testing. Methods: Data on HIV prevalence, RHT sensitivity and specificity, and costs were collected from 820 HIV-exposed children (1.5-18 months) attending 2 postnatal screening programs in Uganda during July 2005 to December 2006. Cost-effectiveness models compared the conventional testing algorithm DNA polymerase chain reaction (DNA-PCR with Roche Amplicor v1.5) with a modified algorithm (initial RHT to screen-out HIV-uninfected infants before DNA-PCR). Results: The model estimated that the conventional algorithm would identify 94.3% (91.8%-94.7%) of HIV-infected infants, compared with 87.8% (79.4%-90.5%) for a modified algorithm using RHT (HIV 1/2 Determine) and excluding the need for DNA-PCR for HIV antibody-negative infants. Costs per infant were $23.47 ($23.32-$23.76) for the conventional algorithm and between $22.75 ($21.89-$23.31) and $7.58 ($6.41-$10.75) for the modified algorithm, depending on infant age and symptoms. Compared with the conventional algorithm, costs per HIV-infected infant identified using the modified algorithm were higher in 1.5- to 3-month-old infants, but significantly lower in 3-month-old and older infants. Models replicating the whole infant testing program showed the modified algorithm would have marginally lower sensitivity, but would reduce total program costs by 27% to 40%, producing an incremental cost-effectiveness ratio of $1489 ($686-$6781) for the conventional versus modified algorithms. Conclusions: Screening infants with RHT before DNA-PCR is cost-effective in infants 3 months old or older. Incorporating RI-IT into early infant testing programs could improve cost-effectiveness and reduce program costs.