Economic

Elective Cesarean cost effective for women with HIV and hepatitis C

Last Updated: 2004-10-05 9:56:40 -0400 (Reuters Health)

By Will Bogs, MD

NEW YORK (Reuters Health) - Elective Cesarean delivery (C-section) is cost effective in preventing vertical hepatitis C (HCV) transmission in women coinfected with HIV, according to a report in the September 3rd issue of AIDS.

C-section significantly protects against HCV transmission by HIV/HCV-coinfected women, the authors explain. Antiviral therapy to prevent maternal HCV transmission is not an option because ribavirin and pegylated alfa-interferon (the standard treatment for chronic HCV) cannot be used during pregnancy.

Dr. Bruce R. Schackman from the Weill Medical College of Cornell University, New York and colleagues used a decision analytic model to investigate the net health consequences, costs, and cost-effectiveness of elective C-section to prevent perinatal transmission of HCV in coinfected women with suppressed HIV RNA but detectable HCV RNA.

In the first scenario (assuming 50% spontaneous HCV clearance in vertically infected infants), C-section resulted in an increase in 0.24 quality-adjusted life-years (QALY) per child and a loss of 0.02 QALY per mother at an incremental cost-effectiveness ratio of $6100/QALY for the net gain in QALY, the authors report.

In the second scenario (assuming 25% spontaneous HCV clearance in vertically infected infants), C-section was associated with an increase in 0.36 QALY per child and a loss of 0.02 QALY per mother, for an incremental cost-effectiveness ratio of $3900/QALY for the larger net gain in QALY.

The cost-effectiveness varied widely between high-cost and low-cost health settings, the researchers note, ranging from $2000/QALY for the second scenario in a low-cost setting to $9100/QALY for the first scenario in a high-cost practice setting.

"C-section may still be indicated for some HIV-infected pregnant women, even if they successfully control their HIV with antiretrovirals," Dr. Schackman told Reuters Health. "These women must be tested for HCV, and they need to receive education about the risk of HCV transmission, the consequences of having an infant infected with HCV, and the potential benefits and risks of an elective C-section to reduce the likelihood of perinatal HCV transmission."

"There have been some studies that suggest that mothers with higher HCV viral loads are more likely to transmit HCV to their infants during vaginal deliveries," Dr. Schackman added. "This would indicate that there may be some threshold HCV load below which a C-section would no longer provide additional benefit."

"In the absence of definitive studies, however, we believe it would be prudent to offer C-section to all HCV detectable/HIV undetectable coinfected women who are not participating in prospective clinical studies."

AIDS 2004;18:1827-1834.