Halperin DT, Stover J, Reynolds HW. Benefits and costs of expanding access to family planning programs to women living with HIV. AIDS. 2009 Nov;23 Suppl 1:S123-30.
To evaluate the cost-benefit of adding family planning services to a national program for prevention of mother-to-child transmission (PMTCT) of HIV. specifically, to estimate the number of preventable infant infections and unintended pregnancies among HIV-infected women
Analyses of data from the 14 countries with the greatest number of HIV-infected pregnant women (four-fifths of the global total), all of which, except for India, were in sub-Saharan Africa
Estimates of number of HIV-infected pregnant women
Data for modeling were derived from UNAIDS reports,(1) the World Health Organization (WHO),(2) and MEASURE Demographic and Health Surveys (DHS).(3) The four elements in the strategy for PMTCT are preventing infection among women, preventing unintended pregnancies among HIV-infected women, preventing perinatal HIV infection, and care for HIV-infected women and their children and families.
Costs per infant infection averted by current PMTCT programs per woman for universal PMTCT were $5 in India and $64 (mean) in sub-Saharan Africa. The rate of perinatal transmission without antiretroviral prophylaxis was assumed to be 20%, plus 15% from breastfeeding (35%); the perinatal rate with antiretroviral prophylaxis was 2%, plus 15% from breastfeeding (17%); thus, 18% (the difference in transmission risk) times the estimated number of HIV-infected pregnant women yields the number of infant HIV infections averted by prophylaxis.
Infant infections averted by family planning for unintended pregnancies were based on fulfilling unmet needs for family planning and estimates of contraceptive effectiveness applied to the number of HIV-positive births occurring even with prophylaxis. Number of unintended births to HIV-infected women that were averted was based on meeting all contraceptive needs.
Costs of averting infant infections or unintended births with family planning were obtained by multiplying the average cost of family planning per user (US $20)(4) by the number of HIV-positive women.(5) Cost per infection or birth averted was estimated by dividing the total number of infections or births prevented by PMTCT or family planning programs by the total cost of the programs.
For the 14 countries, access to the most effective antiretroviral prophylaxis regimens would prevent 241,000 new infant HIV infections a year (302,000 globally); the total annual cost would be $131 million ($208 globally), or $543 per infant infection averted per year. Even with 100% access to antiretroviral prophylaxis, 72,000 infant HIV infections would continue to occur. The annual cost of providing family planning to all HIV-infected women who wish to prevent unintended births is $26 million (about $33 million globally). The estimated cost per additional infant infection averted, by preventing unintended pregnancies with expanded family planning programs, is $359. If all unmet needs for family planning were satisfied for HIV-infected pregnant women, 423,000 births could be prevented, with a cost of $61 per birth averted.
The authors conclude that national strategies that focus on preventing perinatal HIV transmission and unintended pregnancies would be beneficial and highly cost-effective. Eliminating MTCT is not possible with the current limited focus only on providing antiretroviral prophylaxis and information on infant feeding. Expanding access to family planning would not only improve HIV prevention but also would provide other health and social benefits to HIV-infected women and their communities.
This was a high-quality study; however, sensitivity analysis using different assumptions for rates of transmission through breastfeeding was not performed, nor was less than complete uptake of family planning and antiretroviral treatment services taken into account.
Adding family planning addresses the second strategy of the United Nation's four elements of PMTCT.(5) In addition to this study, there have been other analyses showing that preventing unintended pregnancies among HIV-positive women can substantially reduce the number of newly infected infants and contribute to PMTCT cost savings.(6) It also has been shown that even moderate decreases in the number of pregnancies would have the same result as antiretroviral prophylaxis in reducing HIV-positive births.(6) The estimated cost per infection averted in this study is lower than that in other studies; programs providing nevirapine have estimated costs of $298-$9258 per infant infection averted(6) (vs. $543 in this study) and $663 per infant infection averted by family planning (vs. $359 in this study).(7) The rates of HIV transmission from breastfeeding used here could be less than 15% if women are started on highly active antiretroviral therapy and achieve low viral loads.
In addition to reducing the number of infants infected with HIV, the advantages of full access to family planning as part of a national PMTCT strategy are multiple - reducing unwanted pregnancies, the number of orphans, and maternal mortality and morbidity and improving economic opportunities for these women. There appears to be no reason, from the perspective of HIV prevention and care, not to actively include family planning services. It is unlikely that all unmet family planning needs can be addressed, however, or that universal access to antiretroviral prophylaxis can be achieved. The best service delivery approach to providing family planning to HIV-infected women still needs to be established. Increasing contraceptive use among all women through traditional family planning outreach(7) and direct integration within HIV care and treatment programs still need to be scaled up. Integrated maternal and child health clinics that also provide family planning, PMTCT and HIV care would make access for women easier.
- Joint United Nations Programme on HIV/AIDS (UNAIDS). Global resource needs report: financial resources required to achieve universal access to HIV prevention, treatment, care and support. Geneva, Switzerland: UNAIDS; 2007.
- World Health Organization. Toward universal access. Scaling up priority HIV/AIDS interventions in the health sector. Progress report 2008. Geneva, Switzerland: WHO; 2008.
- Demographic and Health Surveys website. Surveys and Methodology. DHS. Accessed 25 August 2010.
- Stover J, Heaton L, Ross J. FamPlan Version 4. A computer program for projecting family planning requirements. Washington, District of Columbia, USA: Future Group; 2006. Abstract not available.
- World Health Organization. Strategic approaches to the prevention of HIV infection in infants: report of a WHO meeting; Morges, Switzerland, 20-22 March 2002. Geneva, Switzerland: WHO; 2003.
- Sweat MD, O'Reilly KR, Schmid GP, Denison J, de Zoysa I. Cost-effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries. AIDS 2004;18:1661-71.
- Reynolds HW, Janowitz B, Homan R, Johnson L. The value of contraception to prevent perinatal HIV transmission. Sex Transm Dis 2006;33:350-6.