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Reynolds HW, Janowitz B, Homan, R, Johnson L. The value of contraception to prevent perinatal HIV transmission. Sex Transm Diseases 2006; 33(2): [Epub ahead of print].
Objective: To highlight the value of preventing unintended pregnancies among HIV-infected women as a strategy to prevent perinatal HIV transmission. Study design: Cost-effectiveness analyses were performed to compare two scenarios, designed to reduce the numbers of HIV infected infants in an African country; a hypothetical health care system was used and evaluated over a one year period. Setting: A hypothetical sub-Saharan African country. Participants: A hypothetical sub-Saharan Africa cohort of 100,000 sexually active women ages 15 Intervention: There was no intervention in this modeling exercise. Two scenarios were compared: 1) Increasing contraceptive use through a family planning program such that 10% of women who do not want a pregnancy but are not using contraception begin using contraception. Costs of the following were included: commodities and their distribution, supplies, personnel, facility overhead, and outreach efforts; or 2) Increasing coverage of nevirapine (from a baseline of 5% to 15%) through a PMTCT program. Costs of the following were included: promotion of HIV testing and prophylaxis, training of existing prenatal care staff in counseling and testing, implementation of pre and post-testing counseling and testing, and nevirapine. Primary outcomes: The two scenarios were compared using the following: 1) number of HIV-positive births averted; 2) cost per HIV-positive birth averted; and 3) number of HIV-positive births averted given a finite investment of $20,000. Results: Increasing current coverage of nevirapine for PMTCT from 5% to 15% would cost $27,857 and would avert 32.5 HIV-positive births in year 1, whereas the family planning intervention would cost $21,957 and avert 33.1 HIV-positive births. The cost per HIV-positive birth averted of a single-dose nevirapine regime was $857, whereas that for the family planning strategy was $663. If $20,000 were available for an intervention to prevent HIV-positive births, increasing contraceptive use among nonusers would avert 30.1 HIV-positive births, whereas targeting that money for nevirapine in a PMTCT program would only prevent 23.4 HIV-positive births ( 22.3% fewer HIV-positive births averted). The results remained relatively robust to sensitivity analyses. The following variables were explored to determine the sensitivity of the results to changes in their realistic values: costs of VCT, neviripine, family planning program; the effectiveness of nevirapine for PMTCT; the proportion of women receiving nevirapine, getting pretest counseling, and accepting testing. If the VCT and nevirapine costs were at their lowest cited value, the number of HIV-positive births averted with the PMTCT program changed to 43.7. If the efficacy of nevirapine improves (65% reduction in mother-to-child transmission), PMTCT becomes the more cost-effective intervention. Conclusions: The authors conclude that increasing contraceptive use among nonusers who do not want to get pregnant is cost-effective and is an equally important strategy in preventing perinatal transmission as PMTCT. Quality rating: This study was of high quality. In context: Currently, funding from the major HIV donors is largely targeted to providing antiretroviral therapy to pregnant women to prevent mother-to-child HIV transmission despite a broader approach defined by the United Nations that includes preventing unintended pregnancies. Previous research has demonstrated the important role of family planning in HIV prevention. This study builds on previous work to consider the contribution that vertically delivered, traditional family planning programs can make in HIV prevention. Programmatic implications: These findings suggest that family planning services and outreach can reduce unintended pregnancies and make a major contribution to averting vertical transmission of HIV. Ideally, family planning should be incorporated in all HIV prevention programs, including PMTCT.

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