Models and analyses for the cost-effectiveness of integrated maternal HIV, syphilis, and hepatitis B screening opt-out strategies in Nepal

Background

The World Health Organisation (WHO) developed a comprehensive framework encouraging an integrated approach to achieve triple elimination of vertical transmission of HIV, syphilis, and hepatitis B in Asia. Current screening practices in Nepal show significantly lower coverage for syphilis and hepatitis B compared to HIV suggesting potential for integration. In this study, we aimed to model the cost-effectiveness of triple screening during antenatal care in Nepal.

Methods

We modelled maternal HIV, hepatitis B and syphilis cascade of care and their corresponding disease states using disease-specific Markov models over a 20-year horizon with a cycle length of one year. We compared dual integrated screening for HIV and syphilis and triple integrated screening for HIV, syphilis and hepatitis B with HIV screening only. Costs were estimated from a provider’s perspective. Results were presented as incremental cost-effectiveness ratios (ICERs). Univariable and probabilistic sensitivity analyses were conducted.

Findings

Our modelling analysis showed that dual-integrated screening for HIV and syphilis was highly cost-effective when compared to current strategy of screening for HIV only (ICERs of US$18). Triple-integrated antenatal screening for HIV, syphilis and hepatitis B was highly cost-effective compared with dual-integrated strategy with an ICER of US$114. Moreover, 100% and 98% of the probabilistic sensitivity analysis estimates for dual- and triple-integrated screening were proven cost-effective, compared to HIV-only screening.

Interpretation

Our results support WHO recommendations for implementing integrated triple antenatal screening in Nepal and Asia more broadly, aiming to reduce maternal and neonatal morbidity through early detection and intervention.