Between HIV diagnosis and initiation of antiretroviral therapy: assessing the effectiveness of care for people living with HIV in the public primary care service in Cape Town, South Africa

Objective To assess the quality of pre‐antiretroviral therapy (ART) care in Cape Town and its continuity with HIV counselling and testing (HCT) and ART. Methods The scale‐up of the HCT, pre‐ART and ART service platform and programmatic support in Cape was described. Data from the August 2010 routine annual HIV/TB/STI evaluation, which included interviews with 133 facility managers and folder reviews of 634 HCT clients who tested positive and 1115 clients receiving pre‐ART HIV care, were analysed. Results Historically, the implementation and management of pre‐ART care has been relatively neglected compared with the scale‐up of HCT and ART. CD4 counts were carried out for 77.5% of positive HCT clients, and 46.6% were clinically staged – crucial steps that determine the care path. There were gaps in quality of care (32.2% of women had a PAP smear), missed opportunities for integrated care (67% were symptomatically screened for tuberculosis) and positive prevention (48.3% had contraceptive needs assessed). Breaks in the continuity of care of pre‐ART clients occurred with only 47.2% of eligible clients referred appropriately to the ARV service. Conclusion While a package of pre‐ART care is clearly defined in Cape Town, it has not been fully implemented. There are weaknesses in the continuity and quality of service delivered that undermine the programme objectives of provision of positive prevention and timely access to ART.     

Treatment outcomes in HIV-infected adolescents attending a community-based antiretroviral therapy clinic in South Africa

Background  

Very few data are available on treatment outcomes of adolescents living with HIV infection (whether perinatally acquired or sexually acquired) in sub-Saharan Africa. The present study therefore compared the treatment outcomes in adolescents with those of young adults at a public sector community-based ART programme in Cape Town, South Africa.     

Antiretroviral treatment and the health workforce in South Africa: how have ART workers been affected by scaling up?

Objective To investigate the effect of scaling up antiretroviral treatment (ART) on the working environment and motivation of health workers in South Africa; and to suggest strategies to minimize negative effects and maximise positive effects. Methods Exploratory interviews with health managers and senior clinical staff were used to identify locally relevant work environment indicators. A self ‐reported Likert scale questionnaire was administered to a randomly selected cohort of 269 health professionals at health facilities in KwaZulu Natal and Western Cape provinces of South Africa that included ART delivery sites. The cohort was disaggregated into ART and non‐ART groups and differences between the two compared with Fisher’s exact test and the non‐parametric Mann–Whitney U‐test. Results The ART sub‐cohort reported: (i) a lighter workload (P = 0.013), (ii) higher level of staffing (P = 0.010), (iii) lower sickness absence (P = 0.032), (iv) higher overall job satisfaction (P = 0.010), (v) poorer physical state of their work premises (P = 0.003), and (vi) higher staff turnover (P = 0.036). Conclusion Scale‐up affects the work environment in ways that influence workers’ motivation both positively and negatively. A net negative balance is likely to drive staff out‐migration, undermine the quality of care and compromise the capacity of the programme to achieve significant scale. As health workers are the most important element of the health system, a comprehensive and systematic understanding of scale‐up impacts on their working conditions and motivation needs to be an integral part of any delivery strategy.     

Piloting antiretroviral treatment in South Africa: the role of partnerships in the Western Cape's provincial roll-out

In 1999, the government of the Western Cape Province, South Africa, entered into a partnership with Médecins Sans Frontières (MSF) to provide HIV treatment through public health clinics in the peri-urban settlement of Khayelitsha. From 2000 onwards, this partnership ran South Africa's first antiretroviral treatment (ART) programme. Due to the province's limited experience (as of 1999) in implementing and monitoring an ART programme, and the National Department of Health's opposition to the public provision of ART, this partnership was instrumental in piloting and later scaling-up the Western Cape's ART programme. Numerous studies have documented this pilot ART programme from a health system or clinical perspective. This study instead used qualitative methods to examine the factors that facilitated the public provision of ART in the Western Cape. With reference to the role of partnerships in piloting new health interventions, the article explores the partnership that was established between the provincial government, civil society organisations, research institutes, and service providers to support the public provision of ART in Khayelitsha. This partnership has demonstrated that ART programmes can be implemented successfully within resource-constrained settings, achieving high levels of treatment adherence, low rates of loss to follow-up and excellent health outcomes. Lessons from the partnership's components and strategies are therefore of vital significance to realising the roll-out of ART programmes in various contexts across the developing world, demonstrating the crucial role of collaboration and integration in the establishment and maintenance of these programmes.     

Pilot programme for the rapid initiation of antiretroviral therapy in pregnancy in Cape Town, South Africa

Initiation of antiretroviral therapy (ART) in pregnancy is an important intervention to prevent the mother-to-child transmission (MTCT) of HIV and to promote maternal health. Early initiation of ART is particularly important to achieve viral suppression rapidly before delivery. However, current approaches to start ART in pregnancy may be problematic in many settings, with referrals between antenatal care (ANC) and ART services, and delays for patient preparation before ART initiation. These steps contribute to a sizable proportion of women failing to receive adequate duration of ART before delivery, increasing the risk of MTCT. To address these limitations, we developed the rapid initiation of antiretroviral therapy in pregnancy (RAP) programme. The programme featured the use of point-of-care CD4 testing to identify ART-eligible women with CD4 cell counts ≤ 350 cells/μl; immediate ART initiation in women on the same day that eligibility was determined, if possible; and intensive counselling and support for ART initiation during the first few weeks on ART. We implemented RAP in an antenatal clinic setting in Cape Town South Africa. Between February and August 2011, a total of 221 HIV-infected women were referred to the programme for CD4 cell count testing and 101 (46%) were eligible for ART. Of these, 98 women (97%) started therapy during pregnancy, 89 (91%) on the day of referral to the service. In-depth interviews suggested that although there were substantial challenges facing HIV-infected women initiating ART in pregnancy, the availability of immediate services and counselling support played an important role in addressing these. While further research is needed, this evaluation demonstrates that a novel service delivery approach may facilitate rapid ART initiation in pregnancy.     

Do self‐assessments of health predict future mortality in rural South Africa? The case of KwaZulu‐Natal in the era of antiretroviral treatment

Objectives While self‐assessments of health (SAH) are widely employed in epidemiological studies, most of the evidence on the power of SAH to predict future mortality originates in the developed world. With the HIV pandemic affecting largely prime age individuals, the strong association between SAH and mortality derived from previous work might not be relevant for the younger at‐risk groups in countries with high HIV prevalence in the era of antiretroviral treatment. We investigate the power of SAH to predict mortality in a community with high HIV prevalence and antiretroviral treatment (ART) coverage using linked data from three sources: a longitudinal demographic surveillance, one of Africa’s largest, longitudinal, population‐based HIV surveillances, and a decentralised rural HIV treatment and care programme. Methods We used a Cox proportional hazards specification to examine whether SAH significantly predicts mortality hazard in a sample composed of 9217 adults aged 15–54, who were followed up for mortality for 8 years. Results Self‐assessments of health strongly predicted mortality (within 4 years of follow‐up), with a clear gradient of the adjusted hazard ratios (aHRs), relative to the baseline of ‘excellent’ self‐assessed health status and controlling for age, gender, marital status, the socio‐economic status (SES), variables education, employment, household expenditures and household assets, and HIV status and ART uptake: 1.40 (95% CI 0.99–1.96) for ‘very good’ self‐assessed health status (SAHS); 2.10 (95% CI 1.52–2.90) for ‘good’ SAHS; 3.12 (95% CI 2.18–4.45) for ‘fair’ SAHS; and 4.64 (95% CI 2.93–7.35) for ‘poor’ SAHS. While a similar association remained in the unadjusted analysis of long‐term mortality (within 4–8 years of follow‐up) the hazard ratios capturing SAH are jointly insignificant in predicting of mortality once HIV status, ART uptake and gender, age, marital status and SES were controlled for. HIV status and ART programme participation were large and highly significant predictors of long‐term mortality. Conclusions Our findings validate SAH as a variable that significantly predicts short‐term mortality in a community in sub‐Saharan Africa with high HIV prevalence, morbidity and mortality. When predicting long‐term mortality, however, it is much more important to know a person's HIV status and ART programme participation than SAH.     

Ensuring HIV‐infected pregnant women start antiretroviral treatment: an operational cohort study from Lilongwe,Malawi

Objectives HIV‐infected women identified through antenatal care (ANC) often fail to access antiretroviral treatment (ART), leaving them and their infants at risk for declining health or HIV transmission. We describe results of measures to improve uptake of ART among eligible pregnant women. Methods Between October 2006 and December 2009, interventions implemented at ANC and ART facilities in urban Lilongwe aimed to better link services for women with CD4 counts <250/μl. A monitoring system followed women referred for ART to examine trends and improve practices in referral completion, on‐time ART initiation and ART retention. Results Six hundred and twelve women were ART eligible: 604 (99%) received their CD4 result, 344 (56%) reached the clinic, 286 (47%) started ART while pregnant and 261 (43%) were either alive on ART or transferred out after 6 months. Between 2006 and 2009, the median (IQR) time between CD4 blood draw and ART initiation fell from 41 days (17, 349) to 15 days (7,42) (P = 0.183); the proportion of eligible individuals starting ART while pregnant and retained for 6 months improved from 17% to 65% (P < 0.001). Delays generally shortened within the continuum of care from 2006 to 2009; however, time from CD4 blood draw to ART referral increased from 7 to 14 days. Conclusions Referrals between facilities and delays through CD4 count measurements create bottlenecks in patient care. Retention improved over time, but delays within the linkage process remained. ART initiation at ANC plus use of point‐of‐care CD4 tests may further enhance ART uptake.     

Low mortality risk but high loss to follow‐up among patients in the Tanzanian national HIV care and treatment programme

Objective To analyse survival and retention rates of the Tanzanian care and treatment programme. Methods Routine patient‐level data were available from 101 of 909 clinics. Kaplan–Meier probabilities of mortality and attrition after ART initiation were calculated. Mortality risks were corrected for biases from loss to follow‐up using Egger’s nomogram. Smoothed hazard rates showed mortality and attrition peaks. Cox regression identified factors associated with death and attrition. Median CD4 counts were calculated at 6 month intervals. Results In 88,875 adults, 18% were lost to follow up 12 months after treatment initiation, and 36% after 36 months. Cumulative mortality reached 10% by 12 months (15% after correcting for loss to follow‐up) and 14% by 36 months. Mortality and attrition rates both peaked within the first six months, and were higher among males, those under 45 kg and those with CD4 counts below 50 cells/μl at ART initiation. In the first year on ART, median CD4 count increased by 126 cells/μl, with similar changes in both sexes. Conclusion Earlier diagnoses through expanded HIV testing may reduce high mortality and attrition rates if combined with better patient tracing systems. Further research is needed to explore reasons for attrition.     

Social exposure to an antiretroviral treatment programme in rural KwaZulu-Natal

Objective To investigate the prevalence of social exposure to a large, government‐run ART programme in rural South Africa. Method Clinical data on 6681 patients were matched with demographic data on a nearly complete cohort of 102 359 people residing in the programme catchment area. We calculated the proportion of residents in the demographic surveillance area that were members of a household, or resided in a compound where someone had initiated ART or received pre‐ART care. Results By January 2010, 3% of the population had initiated ART. However, 25% of the population shared household membership or resided in a compound with someone who had initiated ART; 40% shared household or living arrangements with people who had either initiated ART or were enrolled in pre‐ART care. Conclusion Such high rates of social exposure suggest that ART programmes in HIV endemic areas are likely to have significant population‐level effects on social norms and economic welfare. These results also point to the opportunity to reach large numbers of people with health and social services through existing ART programmes.     

No decrease in annual risk of tuberculosis infection in endemic area in Cape Town,South Africa

Objective To estimate the change in annual risk of tuberculosis infection (ARTI) in two neighbouring urban communities of Cape Town, South Africa with an HIV prevalence of approximately 2%, and to compare ARTI with notification rates and treatment outcomes in the tuberculosis (TB) programme. Methods In 1998–1999 and 2005, tuberculin skin test surveys were conducted to measure the prevalence of Mycobacterium tuberculosis infection and to calculate the ARTI. All 6 to 9‐year‐old children from all primary schools were included in the survey. Notification rates and treatment outcomes were obtained from the TB register. Results A total of 2067 children participated in the survey from 1998 to 1999 and a total of 1954 in 2005. Based on a tuberculin skin test cut‐off point of 10 mm, the ARTI was 3.7% (3.4–4.0%) in the 1998–1999 survey and 4.1% (3.8–4.5%) in 2005. The notification rate for pulmonary TB increased significantly from 646 per 100 000 in 1998 to 784 per 100 000 in 2002. In Ravensmead, there was no significant change in ARTI [first survey: 3.5% (3.1–3.9%), second survey: 3.2% (2.9–3.6%)], but in Uitsig the ARTI increased significantly from 4.1% (3.6–4.6%) to 5.8% (5.2–6.5%). The difference in ARTI between the two areas was associated with differences in reported case rates and the proportion of previously treated cases. Conclusion Tuberculosis transmission remains very high in these two communities and control measures to date have failed. Additional measures to control TB are needed.     

Growth response to antiretroviral treatment in HIV‐infected children: a cohort study from Lilongwe,Malawi

Objective Malnutrition is common in HIV‐infected children in Africa and an indication for antiretroviral treatment (ART). We examined anthropometric status and response to ART in children treated at a large public‐sector clinic in Malawi. Methods All children aged <15 years who started ART between January 2001 and December 2006 were included and followed until March 2008. Weight and height were measured at regular intervals from 1 year before to 2 years after the start of ART. Sex‐ and age‐standardized z‐scores were calculated for weight‐for‐age (WAZ) and height‐for‐age (HAZ). Predictors of growth were identified in multivariable mixed‐effect models. Results A total of 497 children started ART and were followed for 972 person‐years. Median age (interquartile range; IQR) was 8 years (4–11 years). Most children were underweight (52% of children), stunted (69%), in advanced clinical stages (94% in WHO stages 3 or 4) and had severe immunodeficiency (77%). After starting ART, median (IQR) WAZ and HAZ increased from ?2.1 (?2.7 to ?1.3) and ?2.6 (?3.6 to ?1.8) to ?1.4 (?2.1 to ?0.8) and ?1.8 (?2.4 to ?1.1) at 24 months, respectively (P < 0.001). In multivariable models, baseline WAZ and HAZ scores were the most important determinants of growth trajectories on ART. Conclusions Despite a sustained growth response to ART among children remaining on therapy, normal values were not reached. Interventions leading to earlier HIV diagnosis and initiation of treatment could improve growth response.     

Impact of implementing an online interactive educational tool for future HIV “cure” research in an HIV clinic waiting room in Cape Town,South Africa

ABSTRACT

Access to antiretroviral treatment (ART) in South Africa is suboptimal and erratic. For those on treatment, compliance remains a significant challenge. Interruptions to ART have negative implications for the individual and the epidemic. ART is therefore not a sustainable solution and there is an urgent need for a cure. As HIV cure research expands globally, the need to engage community members about cure is becoming a priority. It is vital that potential trial participants understand basic HIV cure research concepts. An online interactive educational tool was co-created with HIV stakeholders to engage and inform HIV research trial participants. The study was conducted with patients at the FAMCRU HIV clinic at Tygerberg Hospital in Cape Town, South Africa. The educational tool comprises two modules that provide information on HIV prevention, treatment and cure research. Participants completed a questionnaire before and after interacting with the programme. There was a significant increase in knowledge scores of participants demonstrated after using the tool. The interactive tool was successful in increasing participants’ knowledge of HIV prevention, treatment and cure research.     

The role of targeted viral load testing in diagnosing virological failure in children on antiretroviral therapy with immunological failure

Objectives To determine the improvement in positive predictive value of immunological failure criteria for identifying virological failure in HIV‐infected children on antiretroviral therapy (ART) when a single targeted viral load measurement is performed in children identified as having immunological failure. Methods Analysis of data from children (<16 years at ART initiation) at South African ART sites at which CD4 count/per cent and HIV‐RNA monitoring are performed 6‐monthly. Immunological failure was defined according to both WHO 2010 and United States Department of Health and Human Services (DHHS) 2008 criteria. Confirmed virological failure was defined as HIV‐RNA >5000 copies/ml on two consecutive occasions <365 days apart in a child on ART for ≥18 months. Results Among 2798 children on ART for ≥18 months [median (IQR) age 50 (21–84) months at ART initiation], the cumulative probability of confirmed virological failure by 42 months on ART was 6.3%. Using targeted viral load after meeting DHHS immunological failure criteria rather than DHHS immunological failure criteria alone increased positive predictive value from 28% to 82%. Targeted viral load improved the positive predictive value of WHO 2010 criteria for identifying confirmed virological failure from 49% to 82%. Conclusion The addition of a single viral load measurement in children identified as failing immunologically will prevent most switches to second‐line treatment in virologically suppressed children.     

Extensively drug‐resistant tuberculosis (XDR‐TB) among health care workers in South Africa

Objective To determine the clinical profile and outcomes of health care workers (HCWs) with extensively drug resistant tuberculosis (XDR‐TB) in the Eastern and Western Cape Provinces of South Africa. Method Retrospective case record review of 334 patients with XDR‐TB reported during the period 1996–2008 from Western and Eastern Cape Province, Cape Town, South Africa. Case records of HCWs with XDR‐TB were analysed for clinical and microbiological features, and treatment outcomes. Results From 334 case records of patients with XDR‐TB, 10 HCWs were identified. Eight of ten were HIV‐uninfected, and four of 10 had died of XDR‐TB despite treatment. All 10 HCWs had received an average of 2.4 courses of TB treatment before being diagnosed as XDR‐TB. Conclusions In the Eastern and Western Cape provinces of South Africa XDR‐TB affects HCWs, is diagnosed rather late, does not appear to be related to HIV status and carries a high mortality. There is an urgent need for the South African government to implement WHO infection control recommendations and make available rapid drug susceptibility testing for HCWs with suspected multidrug‐resistant (MDR)/XDR‐TB. Further studies to establish the actual risk and sources of infection (nosocomial or community) are required.     

Mortality of HIV‐infected and uninfected children in a longitudinal cohort in rural south‐west Uganda during 8 years of follow‐up

Objectives To determine the impact of HIV on child mortality and explore potential risk factors for mortality among HIV‐infected and HIV‐exposed uninfected children in a longitudinal cohort in rural Uganda. Methods From July 2002 to March 2010, HIV‐infected and HIV‐exposed uninfected children aged 6 weeks–13 years were enrolled in an open population‐based clinical cohort. Antiretroviral therapy (ART) was introduced in 2005. Clinical and laboratory data were collected every 3 months. Person‐years at risk were calculated from time of enrolment until earliest date of ART initiation, death or last visit. Cox regression was used to estimate hazard ratios (HR) for mortality. Results Eighty‐nine (30.2%) HIV‐infected and 206 (69.8%) HIV‐exposed but uninfected children were enrolled. Twenty‐one children died. The mortality rate was six times higher in ART‐naive HIV‐infected children than in HIV‐exposed but uninfected children (HR = 6.4, 95% CI = 2.4–16.6). Among HIV‐infected children, mortality was highest in those aged <2 years. Decreasing weight‐for‐age Z (WAZ) score was the strongest risk factor for mortality among HIV‐infected children (HR for unit decrease in WAZ = 2.6, 95% CI = 1.6–4.1). Thirty‐five children (aged 7 months–15.6 years; median, 5.4 years) started ART. Conclusions Mortality among HIV‐infected children was highest among those aged <2 years. Intensified efforts to prevent mother‐to‐child transmission of HIV and ensure early HIV diagnosis and treatment are required to decrease child mortality caused by HIV in rural Africa.     

Initiation of highly active antiretroviral therapy among pregnant women in Cape Town,South Africa

Objective To investigate highly active antiretroviral therapy (HAART) initiation among pregnant women and the optimum model of service delivery for integrating HAART services into antenatal care. Methods We analysed clinic records to reconstruct a cohort of all HIV‐infected pregnant women eligible for HAART at four antenatal clinics representing three service delivery models in Cape Town, South Africa. To assess HAART coverage, records of women determined to be eligible for HAART in pregnancy were reviewed at corresponding HIV treatment services. Results Of 13 208 pregnant women tested for HIV, 26% were HIV‐infected and 15% were HAART‐eligible based on a CD4 cell count of ≤ 200 cells/μl. Among eligible women, 51% initiated HAART before delivery, 27% received another prevention of mother‐to‐child transmission (PMTCT) intervention and 22% did not receive any antiretroviral intervention before delivery. The proportions of women initiating HAART between the different service delivery models were comparable. The median gestational age at first presentation was 26 weeks, and early gestational age at first presentation was the strongest predictor of being on HAART by delivery. Of the women who did not initiate HAART in pregnancy, 24% started treatment within 2 years postpartum. Conclusions In this setting with clear PMTCT and HAART protocols, services failed to prioritize and initiate a high proportion of eligible pregnant women on HAART. The initiation of HAART in pregnancy requires strengthened antenatal and HIV services that target women with advanced stage disease.     

Early loss to follow‐up of recently diagnosed HIV‐infected adults from routine pre‐ART care in a rural district hospital in Kenya: a cohort study

Objective To determine the rate and predictors of early loss to follow‐up (LTFU) for recently diagnosed HIV‐infected, antiretroviral therapy (ART)‐ineligible adults in rural Kenya. Methods Prospective cohort study. Clients registering for HIV care between July 2008 and August 2009 were followed up for 6 months. Baseline data were used to assess predictors of pre‐ART LTFU (not returning for care within 2 months of a scheduled appointment), LTFU before the second visit and LTFU after the second visit. Logistic regression was used to determine factors associated with LTFU before the second visit, while Cox regression was used to assess predictors of time to LTFU and LTFU after the second visit. Results Of 530 eligible clients, 178 (33.6%) were LTFU from pre‐ART care (11.1/100 person‐months). Of these, 96 (53.9%) were LTFU before the second visit. Distance (>5 km vs. <1 km: adjusted hazard ratio 2.6 [1.9–3.7], P < 0.01) and marital status (married vs. single: 0.5 [0.3–0.6], P < 0.01) independently predicted pre‐ART LTFU. Distance and marital status were independently associated with LTFU before the second visit, while distance, education status and seasonality showed weak evidence of predicting LTFU after the second visit. HIV disease severity did not predict pre‐ART LTFU. Conclusions A third of recently diagnosed HIV‐infected, ART‐ineligible clients were LTFU within 6 months of registration. Predictors of LTFU among ART‐ineligible clients are different from those among clients on ART. These findings warrant consideration of an enhanced pre‐ART care package aimed at improving retention and timely ART initiation.     

Costing human rights and community support interventions as a part of universal access to HIV treatment and care in a Southern African setting

Expanding access to antiretroviral therapy (ART) has both individual health benefits and potential to decrease HIV incidence. Ensuring access to HIV services is a significant human rights issue and successful programmes require adequate human rights protections and community support. However, the cost of specific human rights and community support interventions for equitable, sustainable and non-discriminatory access to ART are not well described. Human rights and community support interventions were identified using the literature and through consultations with experts. Specific costs were then determined for these health sector interventions. Population and epidemic data were provided through the Statistics South Africa 2009 national mid-year estimates. Costs of scale up of HIV prevention and treatment were taken from recently published estimates. Interventions addressed access to services, minimising stigma and discrimination against people living with HIV, confidentiality, informed consent and counselling quality. Integrated HIV programme interventions included training for counsellors, 'Know Your Rights' information desks, outreach campaigns for most at risk populations, and adherence support. Complementary measures included post-service interviews, human rights abuse monitoring, transportation costs, legal assistance, and funding for human rights and community support organisations. Other essential non-health sector interventions were identified but not included in the costing framework. The annual costs for the human rights and community support interventions are United States (US) $63.8 million (US $1.22 per capita), representing 1.5% of total health sector HIV programme costs. Respect for human rights and community engagement can be understood both as an obligation of expanded ART programmes and as a critically important factor in their success. Basic rights-based and community support interventions constitute only a small percentage of overall programmes costs. ART programs should consider measuring the cost and impact of human rights and community support interventions as key aspects of successful programme expansion.     

Cost-Effectiveness of a Package of Interventions for Expedited Antiretroviral Therapy Initiation During Pregnancy in Cape Town,South Africa

Initiating antiretroviral therapy (ART) early in pregnancy is an important component of effective interventions to prevent the mother-to-child transmission of HIV (PMTCT). The rapid initiation of ART in pregnancy (RAP) program was a package of interventions to expedite ART initiation in pregnant women in Cape Town, South Africa. Retrospective cost-effectiveness, sensitivity and threshold analyses were conducted of the RAP program to determine the cost-utility thresholds for rapid initiation of ART in pregnancy. Costs were drawn from a detailed micro-costing of the program. The overall programmatic cost was US$880 per woman and the base case cost-effectiveness ratio was US$1,160 per quality-adjusted life year (QALY) saved. In threshold analyses, the RAP program remained cost-effective if mother-to-child transmission was reduced by ≥0.33 %; if ≥1.76 QALY were saved with each averted perinatal infection; or if RAP-related costs were under US$4,020 per woman. The package of rapid initiation services was very cost-effective, as compared to standard services in this setting. Threshold analyses demonstrated that the intervention required minimal reductions in perinatal infections in order to be cost-effective. Interventions for the rapid initiation of ART in pregnancy hold considerable potential as a cost-effective use of limited resources for PMTCT in sub-Saharan Africa.