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In a nutshell
- The Problem: HIV can be transmitted from mother to child during late pregnancy, birth, and breastfeeding. In Africa, it is estimated that without anti-retroviral therapy (ART) 25-35% of HIV positive mothers pass the virus to their infants.
- The Program: ART for the mother and/or child, over a relatively short period of time, aiming to prevent transmission of HIV from mother to child.
- Track record: Randomized trials in the developing world have shown ART to cut mother-to-child transmission (MTCT) by approximately 40% on average.
- Cost-effectiveness: varies widely depending on the specific of what drugs are given and when. The simplest program, a single dose of nevirapine given to mothers in labour and babies immediately after birth, appears to be highly cost-effective, estimated at $150-$300 per HIV infection averted. Studies of other programs have estimated costs of up to $11,444 per HIV infection averted.
- Bottom line: ART for PMTCT is a demonstrably effective and, under the right circumstances, potentially very cost-effective way to prevent HIV/AIDS infections.
- Basics of the program
- Program track record
- Recommendations and concerns
Basics of the program
What is the program? What problem does it target?
Pregnant women infected with HIV/AIDS can transmit the virus to their child during pregnancy, delivery, or while breastfeeding. Without anti-retroviral therapy (ART), the chance that a HIV-positive mother in Africa will pass the virus to her infant is estimated to be 25-35%.1 In Africa, a meta-analysis of seven mother-to-child transmission trials including 3,468 infants found that approximately 50% of those infected with the HIV virus died before the age of two.2
What are the components required to implement this program - how does it work?
- Diagnosis. The World Health Organization (WHO) recommends the use of rapid HIV tests, which allow pregnant women to be tested and receive results in the same clinic visit.4 In areas with high prevalence of HIV among pregnant women, it may be more cost-effective to give ART to all birthing women, thus removing the need for diagnosis.5
- Drugs. Antiretroviral drugs can be costly. (For more, see our cost-effectiveness of ART section here.) Shorter regimens may have significantly lower drug costs.
- Distribution/adherence to drug regimen. A method for ensuring that drugs are reliably taken by pregnant women and their infants at the appropriate times.
Program track record
Micro evidence: Has this program been rigorously evaluated and shown to work?
The Cochrane Review of ART for PMTCT evaluated 18 randomized controlled studies, completed in 16 countries and including over 14,000 participants. These studies used a wide variety of drug regimens which provided different drugs for different durations to mother and/or child. The authors conclude that "Short courses of antiretroviral drugs are effective for reducing mother-to-child transmission of HIV and are not associated with any safety concerns in the short-term."6
Among the regimens recommended in the conclusion is "a single dose of [nevirapine] given to mothers in labour and babies immediately after birth."7
The Disease Control Priorities report estimates that ART reduces MTCT by 33-67%8. A recent review estimates that the specific program mentioned above, "a single dose of NVP given to mothers in labour and babies immediately after birth," reduces transmission by about 40%.9
More on our interpretation of “micro evidence” here.
Macro evidence: Has this program played a role in large-scale success stories?
We have not identified any large-scale success stories in developing countries.
More on our interpretation of “macro evidence” here.
Recommendations and concerns
What are the potential downsides of the intervention?
The Cochrane Review concludes that there have been no safety concerns identified in the short term, but notes that further research is needed to determine if there are long term effects.10 A later study noted a number of complications in pregnancy possibly associated with ART including pre-term delivery, stillbirth, gestational diabetes, pre-eclampsia, and higher risks of anemia and impaired immune systems for infants.11 We have not found clear information on how common or severe such complications are. The study also notes concerns about drug resistance and suggests further research on the topic.12
What is the cost-effectiveness of this intervention?
We have not done thorough cost-effectiveness analysis of this program. Because such analysis is highly time-consuming - and because the results can vary significantly depending on details of the context - we generally do not provide cost-effectiveness analysis for an intervention unless we find what we consider to be a strong associated giving opportunity.
We provide some preliminary figures based on the Disease Control Priorities in Developing Countries report, which we previously used for cost-effectiveness estimates until we vetted its work in 2011, finding major errors that raised general concerns.
The Disease Control Priorities (DCP) report estimates that the when using "a single dose of nevirapine," this program costs $6-$12 per disability-adjusted life year (DALY) averted.13 Using a simple calculation,14 we estimate that $6-$12 per DALY averted is equivalent to $150-$300 per HIV infection averted. (For more on the DALY metric, see our overview of the DALY metric.)
The DCP also cites a number of studies that estimate a considerably higher cost for the use of ART to prevent PMTCT, ranging up to $11,444 per HIV infection averted.15 We would guess that the variation is due to differences in which specific drug regimen is implemented.
- Copenhagen Consensus. Copenhagen Consensus 2008. http://www.copenhagenconsensus.com/Default.aspx?ID=953 (accessed April 16, 2010). Archived by WebCite® at http://www.webcitation.org/5p2vqZV71.
- Jamison, Dean, Prabhat Jha, and David Bloom. 2008. Copenhagen Consensus 2008 challenge paper: Diseases (PDF).
- Jamison, Dean T. et al., eds. 2006. Disease control priorities in developing countries (2nd edition) (PDF). Washington DC: Oxford University Press and The World Bank.
- Maheswaran, Hendramoorthy, and Ruth M. Bland. 2009. Preventing Mother-to-child Transmission of HIV in Resource-limited Settings. Future Virology 4(2):165-175. http://www.medscape.com/viewarticle/589935 (accessed April 20, 2010; free registration required).
- Marseille, E., et al. 1999. Cost effectiveness of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa. Lancet 354: 803-9. Abstract available at http://www.aegis.com/aidsline/1999/dec/A99C0713.html (accessed April 20, 2010). Archived by WebCite® at http://www.webcitation.org/5p8hgoWfv.
- Newell, Marie-Louise. 2004. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. Lancet 364(9441): 1236-1243. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)17140-7/fulltext?_eventId=login (accessed April 20, 2010; free subscription required).
- Volmink, J., et al. 2007. Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database of Systematic Reviews. Summary available at http://www.cochrane.org/reviews/en/ab003510.html (accessed April 20, 2010). Archived by WebCite® at http://www.webcitation.org/5p8i1BPm1.
- World Health Organization. 1998. HIV in Pregnancy: A review (PDF).
"Based on a review of 13 cohort studies the risk of vertical transmission of HIV without antiretroviral treatment was estimated to be about 15-20% in Europe, 15-30% in the USA, and 25-35% in Africa." Volmink et al. 2007, Pg 4.
"Principal investigators of all nine clinical trials undertaken in sub-Saharan Africa were asked to participate in this study; seven agreed to a combined analysis of their mortality data in children of HIV-infected mothers ... 3468 singleton children were included in this analysis ... By age 1 year, an estimated 35Â·2% infected and 4Â·9% uninfected children will have died; by 2 years of age, 52Â·5% and 7Â·6% will have died, respectively." Newell 2004.
- "As higher maternal viral loads are associated with a greater risk of mother-to-child transmission of HIV infection, any intervention that substantially reduces viral load may decrease the likelihood of mother-to-child transmission." Volmink et al. 2007, Pg 5.
- "Antiretroviral drugs can reduce mother-to-child transmission of HIV in one of more the following ways 1) by reducing viral replication and thus lowering plasma viral load in pregnant women; 2) through pre-exposure prophylaxis of babies by crossing the placenta; and 3) through post-exposure prophylaxis of babies after delivery." Volmink et al. 2007, Pg 5.
"The WHO recommends various initiatives to improve initial testing of pregnant women with, at minimum, a rapid HIV test at approximately 20 weeks gestation. Rapid testing has many advantages compared with laboratory-based ELISA testing, including avoiding the transportation of specimens and return clinic appointments for women to receive results, ensuring that women booking late in pregnancy receive their results prior to delivery, and saving time at busy clinics." Maheswaran and Bland 2009.
"For universal treatment with 30% HIV-1 seroprevalence, the HIVNET 012 regimen would avert 603 cases of HIV-1 in babies, cost US$83,333, and generate 15,862 DALYs...For targeted treatment at 30% seroprevalence, HIVNET 012 would cost $141,922 and avert 476 cases at $298 per case averted or $11.29 per DALY. With seroprevalence higher than 3.0% for universal and 4.5% for targeted treatment, the HIVNET 012 regimen was likely to be as cost effective as other public-health interventions." Marseille et al. 1999, abstract.
Volmink et al. 2007, abstract.
"a single dose of NVP given to mothers in labour and babies immediately after birth seems to be effective and feasible." Volmink 2007, abstract.
"Significant reduction in mother-to-infant HIV transmission in the intervention group was found in all eight studies, with a range of 33 to 67 percent reduction in transmission." Jamison et al. 2006, Pg 338 (Table 18.3).
"Single-dose nevirapine (sdNVP) administered to women at the onset of labor and to infants within 72 h of delivery has been widely used in PMTCT programs throughout Africa owing to its feasibility and low cost, reducing transmission by approximately 40%, from a rate of 20% to 12%, at 6-8 weeks postpartum." Maheswaran and Bland 2009.
"Short courses of antiretroviral drugs are effective for reducing mother-to-child transmission of HIV and are not associated with any safety concerns in the short-term ... The long term implications of the emergence of resistant mutations following the use of these regimens require further study." Volmink et al. 2007, abstract.
"Pregnancy-related complications include a risk of pre-term delivery associated with combination ARV, stillbirth, hepatotoxicity in pregnant women (particularly those with CD4 counts >250 cells/mm3) taking NVP, gestational diabetes and pre-eclampsia. AZT has been linked to anaemia and neutropenia in infants." Maheswaran and Bland 2009.
“Viral resistance in women and children previously exposed to ARV prophylaxis during PMTCT programs raises concerns regarding future ART in women and children.” Maheswaran and Bland 2009.
"Prevention of mother-to-child transmission using a single dose of nevirapine in generalized epidemic settings (US $6 to $12 per DALY averted) stands out for its combination of well-documented high cost-effectiveness and significant avertable infections and deaths." Jamison et al. 2006, Pg 43.
25 DALYs per infection averted: "The estimates of cost per disability-adjusted life year (DALY) saved assume a uniform 20 DALYs lost per infected adult (Murray and Lopez 1996) and 25 DALYs lost per infected child (Marseille and others 1999) and do not account for the increasing proportion of people living with HIV/AIDS in developing countries who will have access to antiretroviral therapy over the coming years." Jamison et al. 2006, Pg 344.
See Jamison et al. 2006, Pg 341 (Table 18.4).