This analysis found that it is possible to avert an infant infection at lower than US$483 using any of the two VCT options explored in this study. Couple counselling resulted in the greatest increase in the total programme cost; however, this approach also averted more infant infections. As a result, the cost per infection averted was approximately the same and the cost per DALY saved was also the same as that of the standard antenatal VCT.
In addition, couple counselling has benefits other than those examined in this analysis that are indirectly related to PMTCT because they impact heterosexual HIV-1 transmission. Testing of men that occurs as a result of couple counselling may allow couples in which the female partner is HIV-1 seronegative to prevent acute HIV-1 acquisition during late pregnancy or breastfeeding. Sexual behaviour may also be modified in couples learning that they are concordantly HIV-1 seronegative.
From our sensitivity analysis, we learned that the cost per infection averted decreased with higher rates of male partner participation. There is a need to find out the reasons for low partner involvement in PMTCT and efforts need to be made to increase couple counselling in antenatal VCT as well as in other sites. Men may be unwilling to accompany their female partners to the antenatal clinic making it worthwhile to explore other venues for couple testing or make antenatal clinics more accommodating to male clients.
Finally, we found that the cost per infection averted was lower in the high HIV-1 prevalence areas, which suggests that couple counselling would be more cost-effective in those regions severely hit by the AIDS epidemic. In areas of Western Kenya and Southern Africa where more than 30% of pregnant women test HIV-1 seropositive the cost per DALY would be the lowest and couple VCT would be the most cost-effective.
In conclusion, in cost-effectiveness model based on data collected in a large perinatal HIV-1 transmission cohort, that included couple counselling for VCT, we demonstrate that couple counselling could be cost-effective and could avert more infant HIV-1 infections than standard VCT. Overcoming the challenges of incorporating men and couple counselling into antenatal settings would be beneficial in the long run and worth the investment in resources, time and effort.