Potential cost-effectiveness of maternal and infant antiretroviral interventions to prevent mother-to-child transmission during breast-feeding.

INTRODUCTION One-third of maternal-to-child HIV transmission occurs during breast-feeding (BF). Several trials are currently evaluating the efficacy of postpartum antiretrovirals to reduce BF transmission. METHODS This study used Markov modeling to define the circumstances under which the following interventions would be cost-effective: BF for 6 months with daily infant nevirapine (NVP) prophylaxis; maternal combination antiretroviral therapy (ART) during pregnancy and for 6 months of BF; and maternal combination ART only for women who meet CD4 criteria. Each was compared to: BF for 12 months; BF for 6 months; and formula feeding for 12 months. Strategies were evaluated for a hypothetical cohort of 40,000 pregnant women in sub-Saharan Africa, in the context of available voluntary counseling and testing in antenatal care. Model estimates were derived from the literature and local sources. Sensitivity analyses were performed on uncertain estimates. The perspective used was that of a government health district. RESULTS Using base case estimates, BF for 6 months was the economically preferred strategy: it cost 806,995 dollars and generated 446,208 quality-adjusted life-years (QALYs). Providing daily infant NVP cost an additional 93,638 dollars and generated 1183 additional QALYs, but its incremental cost-effectiveness ratio (ICER) of 79 dollars/QALY exceeded the standard willingness to pay (64 dollars/QALY) for most resource-poor settings. Maternal combination ART was potentially very effective but too costly for most resource-poor settings (ICER: 87 dollars/QALY). In order for daily infant NVP during BF to be preferred, it must have >/=44% relative efficacy or cost </=5.00 dollars/mo. If NVP were donated, it would only have to be minimally effective to be the economically preferred strategy. If ART cost </=34.50 dollars/mo, ART to all mothers would become the preferred strategy under our assumption of 82% efficacy. CONCLUSIONS Providing antiretrovirals during BF represents a promising alternative, should their effectiveness, and feasibility be proven.