Cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine for malaria during pregnancy: an analysis using efficacy results from Uganda and Kenya, and pooled data.
Cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine for malaria during pregnancy: an analysis using efficacy results from Uganda and Kenya, and pooled data.
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DOI：
10.1016/s2214-109x(20)30369-7
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发表时间：
2020-12
期刊：
影响因子：
--
通讯作者：
Hanson K
中科院分区：
文献类型：
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作者：
Fernandes S;Were V;Gutman J;Dorsey G;Kakuru A;Desai M;Kariuki S;Kamya MR;Ter Kuile FO;Hanson K
目前，预防艾滋病毒阴性妇女孕期感染疟疾有赖于使用长效杀虫蚊帐，并在孕期间歇使用磺胺多辛-乙胺预防治疗(IPTp-SP)。在非洲，磺胺多辛-乙胺嘧啶耐药性的增加威胁到目前对妊娠期疟疾的预防。因此，迫切需要一种IPTp-SP的替代品，特别是对于磺胺多辛-乙胺嘧啶抗性较高的地方。双氢青蒿素-哌喹是一种很有前途的候选药物。我们的目的是评估双氢青蒿素-哌喹(IPTp-DP)与双氢青蒿素-哌喹(IPTp-SP)在预防妊娠期临床疟疾感染(及其后遗症)方面的成本-效果。我们使用荟萃分析和在肯尼亚和乌干达进行的三项临床试验的个人试验结果进行了成本效益分析。我们计算了死产、新生儿死亡、低出生体重、轻度和中度孕产妇贫血以及与孕期疟疾相关的临床疟疾感染引起的残疾调整寿命年(DALY)。成本估算是从观察性研究、卫生设施成本计算和国际药品采购数据库中收集的数据中获得的。成本效益分析是从卫生保健提供者的角度使用具有终生视野的决策树模型进行的。还利用适当的参数范围和分布进行了确定性和概率敏感性分析。结果以避免的每DALY增量成本和干预对于不同成本效益阈值的成本效益的可能性来表示。与三剂磺胺多辛-乙胺嘧啶相比，三剂双氢青蒿素-哌喹，给1,000名孕妇的假设队列，避免了892DALY(95%可信区间274至1517)，增加了成本7,051美元(2,653至13 038)，产生了每避免DALY 8美元(2至29)的增量成本-效果比。与每月剂量的磺胺多辛-乙胺嘧啶相比，每月剂量的双氢青蒿素-哌喹减少了534DALY(−141至1233)，成本为13 427(4,994至22 895)，导致每避免DALY的ICER为25美元(−151至224)。这两个结果对确定性敏感性分析中的大多数或所有变化都具有很强的稳健性。我们的发现表明，在HIV阴性的孕妇中，在长期使用杀虫蚊帐的情况下，IPTp-DP在疟疾传播率高和磺胺多辛-乙胺耐药性高的地区是具有成本效益的。这些数据全面概述了目前关于IPTp-DP成本效益的证据。然而，在提倡政策改变之前，我们建议进一步研究不同方案的IPTp-DP在具有不同的磺胺多辛-乙胺嘧啶耐药性的环境中的有效性和成本。孕期疟疾联盟，该联盟由比尔和梅林达·盖茨基金会向利物浦卫生和热带医学院提供赠款资助。
Prevention of malaria infection during pregnancy in HIV-negative women currently relies on the use of long-lasting insecticidal nets together with intermittent preventive treatment in pregnancy with sulfadoxine–pyrimethamine (IPTp-SP). Increasing sulfadoxine–pyrimethamine resistance in Africa threatens current prevention of malaria during pregnancy. Thus, a replacement for IPTp-SP is urgently needed, especially for locations with high sulfadoxine–pyrimethamine resistance. Dihydroartemisinin–piperaquine is a promising candidate. We aimed to estimate the cost-effectiveness of intermittent preventive treatment in pregnancy with dihydroartemisinin–piperaquine (IPTp-DP) versus IPTp-SP to prevent clinical malaria infection (and its sequelae) during pregnancy. We did a cost-effectiveness analysis using meta-analysis and individual trial results from three clinical trials done in Kenya and Uganda. We calculated disability-adjusted life-years (DALYs) arising from stillbirths, neonatal death, low birthweight, mild and moderate maternal anaemia, and clinical malaria infection, associated with malaria during pregnancy. Cost estimates were obtained from data collected in observational studies, health-facility costings, and from international drug procurement databases. The cost-effectiveness analyses were done from a health-care provider perspective using a decision tree model with a lifetime horizon. Deterministic and probabilistic sensitivity analyses using appropriate parameter ranges and distributions were also done. Results are presented as the incremental cost per DALY averted and the likelihood that an intervention is cost-effective for different cost-effectiveness thresholds. Compared with three doses of sulfadoxine–pyrimethamine, three doses of dihydroartemisinin–piperaquine, delivered to a hypothetical cohort of 1000 pregnant women, averted 892 DALYs (95% credibility interval 274 to 1517) at an incremental cost of US$7051 (2653 to 13 038) generating an incremental cost-effectiveness ratio (ICER) of $8 (2 to 29) per DALY averted. Compared with monthly doses of sulfadoxine–pyrimethamine, monthly doses of dihydroartemisinin–piperaquine averted 534 DALYS (−141 to 1233) at a cost of $13 427 (4994 to 22 895), resulting in an ICER of $25 (−151 to 224) per DALY averted. Both results were highly robust to most or all variations in the deterministic sensitivity analysis. Our findings suggest that among HIV-negative pregnant women with high uptake of long-lasting insecticidal nets, IPTp-DP is cost-effective in areas with high malaria transmission and high sulfadoxine–pyrimethamine resistance. These data provide a comprehensive overview of the current evidence on the cost-effectiveness of IPTp-DP. Nevertheless, before a policy change is advocated, we recommend further research into the effectiveness and costs of different regimens of IPTp-DP in settings with different underlying sulfadoxine–pyrimethamine resistance. Malaria in Pregnancy Consortium, which is funded through a grant from the Bill & Melinda Gates Foundation to the Liverpool School of Hygiene and Tropical Medicine.