Early infant HIV diagnosis (EID) and antiretroviral therapy dramatically reduce mortality. EID is recommended at six weeks of age, but many infant infections are missed.
We simulated four EID strategies for HIV-exposed infants in South Africa: no EID (diagnosis only after illness), testing once (birth alone; 6 weeks alone) and twice (birth and 6 weeks). We calculated incremental cost-effectiveness ratios (ICERs) using discounted costs and life expectancies for all HIV-exposed (infected and uninfected) infants.
In the base case (guideline-concordant care), no EID produced a life expectancy of 21.1y (HIV-infected) and 61.1y (HIV-exposed); lifetime cost averaged $1,430/HIV-exposed infant. The birth and 6 weeks strategy maximized life expectancy (HIV-infected: 26.5y; HIV-exposed: 61.4y), costing $1,840/infant tested. The ICER of 6 weeks alone vs. no EID was $1,250/year of life saved (YLS, 19% of South Africa’s per-capita GDP); birth and 6 weeks vs. 6 weeks alone was $2,900/YLS (45% of GDP). Increasing result-return and linkage to ART with 6 weeks alone improved survival more than adding a second test.
EID at birth and 6 weeks improves outcomes and is cost-effective, compared to 6 weeks alone If scale-up costs are comparable, programs should add birth testing after strengthening 6-week testing programs.