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The cost-effectiveness of human immunodeficiency virus screening in pregnancy
Citations from the literature I International Journal o$ Gynecology & Obstetrics 54 (1996) 307-316
MeotI6ation ofIeveIs of matend rIskofperImtaIr lreataeatellvImIIod
HIV-1 RNA essedated wItb ~ioa:effectofm8tendzMovudb
Dickover R.E.; Garratty EM.; Herman S.A.; Sim M.-S.; Plaeger S.; Boyer P.J.; Keller M.; Deveikis A.; Stiehm E.R.; Bryson Y.J. USA J AM MED ASSGC 1996275/8(X??-605) Objective. To determine if there arr levels of HIV-l associated with a high or low risk of perinatal transmission and to ascertain the mechanism by which xidovudine treatment reduces perinatal transmission. Design. A non-randomized prospective cohort study. Setting. University medical center and two general hospital affiiates, from May 1989 to September 1994. Patients. Ninety-two HIV- 1-seropositive women (95 pregnancies) and their 97 infants. Intervention. Forty-two mothers (43 pregnancies)received xidovudine therapy during pregnancy and/or during labor and delivery. Eleven infants received prophylactic xidovudine for the first 6 weeks after delivery. Main outcome measure. HIV-I infection status of the infant. Rest&s. Twenty of the 97 infants were perinatally infected with HIV- 1. Transmitting mothers were more likely to have plasma HIV-l RNA levels higher than 50 000 copies per milliliter at delivery than non-transmitting mothers (15 [75.0%] of 20 transmitters vs. four [5.3%] of 75 non-transmitters; P < 0.001). None of the 63 women with less than 20000 HIV-I RNA copies per milliliter transmitted. Twenty-two women treated with open-label oral xidovudine during gestation showed an 8-fold median decmase in plasma RNA levels (median [25th and 75th percentile] 43 043 [5699 and 63 0531copies per milliliter before xidovudine vs. 4238 [603 and 51161 HIV-l RNA copies per milliliter at delivery; P < 0.001) and none transmitted. Four xidovudine-treated women with high HIV-I levels transmitted despite the presence of xidovudine-sensitive virus in vitro in both the mothers and their infants. Conclusions. Maternal HIV-l RNA levels were highly predictive of perinatal transmission risk and suggest that certain levels of virus late in gestation and/or during labor and delivery are associatedwith both a high risk and a low risk of transmission. Our results also suggestthat xidovudine exerts a major protective e&t by reducing maternal HIV-l RNA levels prior to delivery and that further strategiesare neededto prevent perinatal transmission in women with high or increasing virus levels and/or xidovudinotesistant virus. ofIllmanImmimoMcbqvImaeereenThaLYJaMff4~Pmw-Y Ecker J.L. USA AM J OBSTET GYNECOL 1996 174/2(716-721) Objective. My purpose was to evaluate the costsffectiveness of screeningfor HIV during pregnancy as part of a protocol in which xidovudine was used to reduce the risk of vertical transmission. Study design. This mathematic model used decision analysis to calculate the marginal cost-effectivenessof screening for HIV in pregnancy and treating HIV-positive women with xidovudine. Cost and probability assumptionswere drawn
313
from a literature review. Sensitivity analyses were performed for important costs and probabilities. Results. When baseline cost and probability assumptionswere used, the marginal costeffectivenessof HIV screening was 16436927 when the prevalence of HIV in the population was low (0.08075)and $198510 when the prevalence was average.(0.0015).Above a prevalence of HIV of 0.009,testing is both cheaper and more effective than not testing. Gf the cost variables examined, the charge for a negative testing sequence had the greatest impact on costeffectiveness.Conclusion. HIV testing in pregnancy is costeffective in populations in which the prevalence of HIV exceeds 9 per 1000 population. Depending on how individual lives saved are valued, screening may also be warranted in populations with lower prevakmcesOf infection. MuRIpIe~ofeervkmIIutrae@theIIaIneopIasirht -wIthnlehara~vIrus Fruchter R.G.; Maiman M.; Sedlis A.; Bartley L.; Camilien L.; Arrastia C.D. USA
OBSTET GYNECGL 199687/3 (338-344) Objective. To evaluate the long-term outcomes after treatment of cervical intraepithelial neoplasia (GIN) in women infected with HIV. Methods. HIV-infected and HIV-negative women treated for CIN by ablation or excision were followed up prospectively by cytology and colposcopy for periods of up to 73 months. Results. Among 127HIV-infected CIN patients, 62% developed recmrent CIN by 36 months after treatment, compared with 18%of 193HIV-negative CIN patients. Recurrence rates reached 87% in 41 HIV-infected women with CD4 counts < 200cells/mm3.Progressionto higher grade neoplasia, including one invasive cancer, occurred by 36 months in 25% of HIV-infected and 2% of HIV-negative women. After adjusting for age, CIN severity and treatment type, predictors of recurrenceincluded HIV infection (rate ratio 4.4) and, in HIVpositive women, low CD4 count (rate. ratio 2.2). In patients treated by excision, predictors of recurrence included HIV infection (rate ratio 2.0) and residual CIN after treatment (rate ratio 2.7). After a second treatment, a second CIN recurrence developed in 14 of 33 HIV-infected and in one of 17 HIVnegative women. After a third treatment, three of six HIVinfected women developed a third recurrence. With long-term follow-up, 45% of treated HIV-infected CIN patients had chronic condylomatous changes in the cervix compared with 5% of HIV-negative women. Conclusion. In HIV-infected women, CIN may recur despite multiple treatments, and chronic condylomatous changes are common. Innovative therapies for controlling CIN in HIV-infected women are needed.
GYNECOLOGICAL
SURGERY
vagiuIb;yrtacrtomYf~~luee-
Magos A.; Boumas N.; Sinha R.; Richardson R.E.; O’Cotmor H. GBR BR J GBSTET GYNAECOL 1996 10313(246-251) Objective. To assessthe feasibility and safety of performing
MeotI6ation ofIeveIs of matend rIskofperImtaIr lreataeatellvImIIod
HIV-1 RNA essedated wItb ~ioa:effectofm8tendzMovudb
Dickover R.E.; Garratty EM.; Herman S.A.; Sim M.-S.; Plaeger S.; Boyer P.J.; Keller M.; Deveikis A.; Stiehm E.R.; Bryson Y.J. USA J AM MED ASSGC 1996275/8(X??-605) Objective. To determine if there arr levels of HIV-l associated with a high or low risk of perinatal transmission and to ascertain the mechanism by which xidovudine treatment reduces perinatal transmission. Design. A non-randomized prospective cohort study. Setting. University medical center and two general hospital affiiates, from May 1989 to September 1994. Patients. Ninety-two HIV- 1-seropositive women (95 pregnancies) and their 97 infants. Intervention. Forty-two mothers (43 pregnancies)received xidovudine therapy during pregnancy and/or during labor and delivery. Eleven infants received prophylactic xidovudine for the first 6 weeks after delivery. Main outcome measure. HIV-I infection status of the infant. Rest&s. Twenty of the 97 infants were perinatally infected with HIV- 1. Transmitting mothers were more likely to have plasma HIV-l RNA levels higher than 50 000 copies per milliliter at delivery than non-transmitting mothers (15 [75.0%] of 20 transmitters vs. four [5.3%] of 75 non-transmitters; P < 0.001). None of the 63 women with less than 20000 HIV-I RNA copies per milliliter transmitted. Twenty-two women treated with open-label oral xidovudine during gestation showed an 8-fold median decmase in plasma RNA levels (median [25th and 75th percentile] 43 043 [5699 and 63 0531copies per milliliter before xidovudine vs. 4238 [603 and 51161 HIV-l RNA copies per milliliter at delivery; P < 0.001) and none transmitted. Four xidovudine-treated women with high HIV-I levels transmitted despite the presence of xidovudine-sensitive virus in vitro in both the mothers and their infants. Conclusions. Maternal HIV-l RNA levels were highly predictive of perinatal transmission risk and suggest that certain levels of virus late in gestation and/or during labor and delivery are associatedwith both a high risk and a low risk of transmission. Our results also suggestthat xidovudine exerts a major protective e&t by reducing maternal HIV-l RNA levels prior to delivery and that further strategiesare neededto prevent perinatal transmission in women with high or increasing virus levels and/or xidovudinotesistant virus. ofIllmanImmimoMcbqvImaeereenThaLYJaMff4~Pmw-Y Ecker J.L. USA AM J OBSTET GYNECOL 1996 174/2(716-721) Objective. My purpose was to evaluate the costsffectiveness of screeningfor HIV during pregnancy as part of a protocol in which xidovudine was used to reduce the risk of vertical transmission. Study design. This mathematic model used decision analysis to calculate the marginal cost-effectivenessof screening for HIV in pregnancy and treating HIV-positive women with xidovudine. Cost and probability assumptionswere drawn
313
from a literature review. Sensitivity analyses were performed for important costs and probabilities. Results. When baseline cost and probability assumptionswere used, the marginal costeffectivenessof HIV screening was 16436927 when the prevalence of HIV in the population was low (0.08075)and $198510 when the prevalence was average.(0.0015).Above a prevalence of HIV of 0.009,testing is both cheaper and more effective than not testing. Gf the cost variables examined, the charge for a negative testing sequence had the greatest impact on costeffectiveness.Conclusion. HIV testing in pregnancy is costeffective in populations in which the prevalence of HIV exceeds 9 per 1000 population. Depending on how individual lives saved are valued, screening may also be warranted in populations with lower prevakmcesOf infection. MuRIpIe~ofeervkmIIutrae@theIIaIneopIasirht -wIthnlehara~vIrus Fruchter R.G.; Maiman M.; Sedlis A.; Bartley L.; Camilien L.; Arrastia C.D. USA
OBSTET GYNECGL 199687/3 (338-344) Objective. To evaluate the long-term outcomes after treatment of cervical intraepithelial neoplasia (GIN) in women infected with HIV. Methods. HIV-infected and HIV-negative women treated for CIN by ablation or excision were followed up prospectively by cytology and colposcopy for periods of up to 73 months. Results. Among 127HIV-infected CIN patients, 62% developed recmrent CIN by 36 months after treatment, compared with 18%of 193HIV-negative CIN patients. Recurrence rates reached 87% in 41 HIV-infected women with CD4 counts < 200cells/mm3.Progressionto higher grade neoplasia, including one invasive cancer, occurred by 36 months in 25% of HIV-infected and 2% of HIV-negative women. After adjusting for age, CIN severity and treatment type, predictors of recurrenceincluded HIV infection (rate ratio 4.4) and, in HIVpositive women, low CD4 count (rate. ratio 2.2). In patients treated by excision, predictors of recurrence included HIV infection (rate ratio 2.0) and residual CIN after treatment (rate ratio 2.7). After a second treatment, a second CIN recurrence developed in 14 of 33 HIV-infected and in one of 17 HIVnegative women. After a third treatment, three of six HIVinfected women developed a third recurrence. With long-term follow-up, 45% of treated HIV-infected CIN patients had chronic condylomatous changes in the cervix compared with 5% of HIV-negative women. Conclusion. In HIV-infected women, CIN may recur despite multiple treatments, and chronic condylomatous changes are common. Innovative therapies for controlling CIN in HIV-infected women are needed.
GYNECOLOGICAL
SURGERY
vagiuIb;yrtacrtomYf~~luee-
Magos A.; Boumas N.; Sinha R.; Richardson R.E.; O’Cotmor H. GBR BR J GBSTET GYNAECOL 1996 10313(246-251) Objective. To assessthe feasibility and safety of performing