Autor/a:
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Sicuri, Elisa; Fernandes, Silke; Macete, Eusébio; González, Raquel; Mombo-Ngoma, Ghyslain; Massougbodji, Achille; Abdulla, Salim; Kuwawenaruwa, August; Katana, Abraham; Desai, Meghna; Cot, Michel; Ramharter, Michael; Kremsner, Peter G.; Slutsker, Laurence; Aponte, John J.; Hanson, Kara; Menéndez, Clara
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Abstract:
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Intermittent preventive treatment in pregnancy
(IPTp) with sulfadoxine-pyrimethamine (SP) is recommended in
HIV-negative women to avert malaria, while this relies on
cotrimoxazole prophylaxis (CTXp) in HIV-positive women.
Alternative antimalarials are required in areas where parasite
resistance to antifolate drugs is high. The cost-effectiveness
of IPTp with alternative drugs is needed to inform policy.
METHODS: The cost-effectiveness of 2-dose IPTp-mefloquine (MQ)
was compared with IPTp-SP in HIV-negative women (Benin, Gabon,
Mozambique and Tanzania). In HIV-positive women the
cost-effectiveness of 3-dose IPTp-MQ added to CTXp was compared
with CTXp alone (Kenya, Mozambique and Tanzania). The outcomes
used were maternal clinical malaria, anaemia at delivery and
non-obstetric hospital admissions. The poor tolerability to MQ
was included as the value of women's loss of working days.
Incremental cost-effectiveness ratios (ICERs) were calculated
and threshold analysis undertaken. RESULTS: For HIV-negative
women, the ICER for IPTp-MQ versus IPTp-SP was 136.30 US$ (2012
US$) (95%CI 131.41; 141.18) per disability-adjusted life-year
(DALY) averted, or 237.78 US$ (95%CI 230.99; 244.57), depending
on whether estimates from Gabon were included or not. For
HIV-positive women, the ICER per DALY averted for IPTp-MQ added
to CTXp, versus CTXp alone was 6.96 US$ (95%CI 4.22; 9.70). In
HIV-negative women, moderate shifts of variables such as malaria
incidence, drug cost, and IPTp efficacy increased the ICERs
above the cost-effectiveness threshold. In HIV-positive women
the intervention remained cost-effective for a substantial (up
to 21 times) increase in cost per tablet. CONCLUSIONS: Addition
of IPTp with an effective antimalarial to CTXp was very
cost-effective in HIV-positive women. IPTp with an efficacious
antimalarial was more cost-effective than IPTp-SP in
HIV-negative women. However, the poor tolerability of MQ does
not favour its use as IPTp. Regardless of HIV status, prevention
of malaria in pregnancy with a highly efficacious, well
tolerated antimalarial would be cost-effective despite its high
price. TRIALS REGISTRATION: ClinicalTrials.gov NCT 00811421; Pan
African Trials Registry PACTR2010020001429343 and
PACTR2010020001813440. |