Opt-Out Model of HIV Screening- A Study in Federal Capital Territory Abuja, Nigeria

Background: Nigeria is the most burdened with mother to child transmission (MTCT) of HIV, accounting for nearly one-third of the global prevalence in 2015. Advances in the treatment of MTCT of HIV with highly active antiretroviral therapy (HAART) suggest significant reductions in transmission rates from ≥ 30% to ≤ 1%. HIV testing is the linchpin to the treatment, but low-test acceptance is still prevalent among pregnant women including those attending antenatal clinics (ANC). The World Health Organization (WHO) issued new guidelines for improving HIV testing in ANC; recommending provider-initiated routine testing approach, different from the current on-request client-led voluntary counselling and testing (VCT). However, the adoption of such a strategy requires settings’ understanding of both the clinical and economic impact. Objective: To evaluate the clinical and economic impact of routine offer of antenatal HIV testing for PMTCT in an urban health facility in North Central Nigeria. Study design: A pre-post (before and after) non-randomized controlled study was conducted. Methods: Midwife counsellors were trained to provide and recommend HIV testing to all the women attending ANC, using streamlined counselling. Data in ANC logbook was extracted and key outcomes during the 3-months client-initiated testing were compared with a 3-months record during the implementation of routine offer of HIV testing strategy. Results: After the introduction of routine HIV testing, the proportion of pregnant women in the study site who underwent and learned their HIV status increased from 142(46.4%) to 292 (94.5%) and HIV-positive cases identified rose from 15 (10.1%) to 44(15%). HIV positive women receiving treatment intervention for PMTCT increased from 10(66%) to 44(100%). 5 Aggregate cost and cost per unit testing were £38183.50 and £20204.80 and £130.70 and £136 for routine and client-initiated approaches, respectively. Cases of HIV infection averted in children during routine testing were 34.32 compared with the client-initiated approach of 10.8. Additional cost per HIV averted was £398.42 while the incremental cost-effectiveness ratio (ICER) was £764.40. Conclusion: Provider-initiated HIV testing was both clinically and economically effective. Routine testing led to a substantial increase in test acceptance and reductions in transmission rates at ICER value below the recommended threshold (ICER below three times the gross domestic product: $2,177.99 for Nigeria). In the context of policy goal in maximizing limited HIV resources, this study suggests that there may be considerable benefits in the provision of HCT, using routine testing strategy. The efficient adoption of the policy should be based on local contextual considerations such as the prevalence and availability of human resources