Maredza Mandy, Bertram Melanie Y, Saloojee Haroon, Chersich Matthew F, Tollman Stephen M, Hofman Karen J
a MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences , University of the Witwatersrand , Parktown 2193 , Johannesburg , South Africa.
Afr J AIDS Res. 2013 Sep;12(3):151-60. doi: 10.2989/16085906.2013.863215.
Despite increasing availability of perinatal interventions to prevent mother-to-child transmission (MTCT) of HIV in South Africa, MTCT remains high due to breastfeeding. To inform policy decisions in the country, cost-effectiveness of alternative infant-feeding interventions was conducted. Mathematical modelling was used to simulate post-natal transmission and mortality due to infant feeding in a hypothetical cohort of 1 000 HIV-exposed infants. Lifetime costs to the health system were calculated for each strategy. Interventions compared with current practice were: increasing coverage of extended nevirapine prophylaxis (ENP) to infants from 30% (base case) to 60% without changing current feeding practices; actively supporting breastfeeding with ENP to infants for 12 months; and actively supporting exclusive formula (replacement) feeding for 6 months. HIV-free survival at 24 months and disability-adjusted life years (DALYs) averted were estimated for typical rural and certain urban settings. Base-case analysis revealed that expanding coverage of nevirapine prophylaxis with breastfeeding is cost-saving and improves HIV-free survival. Changing feeding practices is beneficial, depending on context. Breastfeeding is dominant (less costly, more effective) in rural settings, whilst formula feeding is a dominant strategy in urban settings. Cost-effectiveness was most sensitive to proportion of women on lifelong antiretroviral therapy (ART) and infant mortality rate (IMR). When >55% of women are on ART, breastfeeding dominates in the urban settings modelled, whilst formula feeding is cost-effective in rural settings when IMR ≤ 45/1000. The study concludes that strategies to support breastfeeding are essential. Strengthening health systems is critical to ensure optimal nevirapine delivery during breastfeeding. A case can be made for formula feeding or breastfeeding in HIV-infected women in specific contexts.
尽管南非预防母婴传播艾滋病毒的围产期干预措施越来越普及,但由于母乳喂养,母婴传播率仍然很高。为了为该国的政策决策提供依据,对替代婴儿喂养干预措施的成本效益进行了研究。采用数学模型模拟了1000名艾滋病毒暴露婴儿的假想队列中因婴儿喂养导致的产后传播和死亡率。计算了每种策略对卫生系统的终身成本。与当前做法相比的干预措施包括:将婴儿接受奈韦拉平强化预防(ENP)的覆盖率从30%(基础情况)提高到60%,同时不改变当前的喂养方式;通过ENP积极支持婴儿母乳喂养12个月;以及积极支持婴儿纯配方奶(替代)喂养6个月。估计了典型农村和某些城市环境中24个月时的无艾滋病毒生存率和避免的残疾调整生命年(DALYs)。基础情况分析表明,在母乳喂养的同时扩大奈韦拉平预防的覆盖率可节省成本并提高无艾滋病毒生存率。根据具体情况,改变喂养方式是有益的。母乳喂养在农村环境中占主导地位(成本更低、更有效),而配方奶喂养在城市环境中是主导策略。成本效益对接受终身抗逆转录病毒治疗(ART)的妇女比例和婴儿死亡率(IMR)最为敏感。当超过55%的妇女接受ART时,在模拟的城市环境中母乳喂养占主导地位,而当IMR≤45/1000时,配方奶喂养在农村环境中具有成本效益。该研究得出结论,支持母乳喂养的策略至关重要。加强卫生系统对于确保母乳喂养期间奈韦拉平的最佳给药至关重要。在特定情况下,可以考虑为感染艾滋病毒的妇女采用配方奶喂养或母乳喂养。