Figures & Tables
Figures
- FIGURE
Decision Analysis Model
Abbreviations: ARVs, antiretrovirals; COCs, combined oral contraceptives; IUD, intrauterine device; POI, progestin-only injectable.
All branches are followed to the same outcome of life expectancy; truncated here for clarity. Red triangles represent terminal nodes while green circles represent decision nodes.
When calculating the number of HIV cases averted if no POIs were available, we considered 2 scenarios for women currently using POIs: (1) they all switch to no method, and (2) they switch to another reversible modern method (COCs, an IUD, or an implant).
Tables
Variable All Regions Increase in HIV acquisition with POI use28 40% Average maternal age at time of birth 25 years Reduction in life expectancy for women with HIV on ART38 25% Reduction in life expectancy for women with HIV not on ART38 75% Probability of maternal-to-child transmission of HIV if ARVs used in labor40 2% Probability of maternal-to-child transmission of HIV if ARVs not used in labor40 25% Standard discount ratea,39 3% Regional Inputs Central Africa Eastern Africa Southern Africa Western Africa Chad DRC Kenya Tanzania Uganda Malawi South Africa Burkina Faso Senegal Life expectancy (years)41 51.5 58.7 61.6 65.0 58.5 62.7 57.2 58.2 66.4 HIV36 HIV incidence .001 .0003 .003 .002 .005 .004 .015 .0005 .0001 Probability of ARVs in labor .46 .67 .74 .86 .97 .79 .99 .89 .36 Probability of accessing ARVs .36 .33 .59 .57 .57 .61 .48 .54 .40 Contraceptive use8,9 POIs .09 .012 .14 .087 .14 .32 .28 .061 .052 COCs .005 .007 .07 .06 .03 .02 .05 .02 .041 Implant .00 .007 .016 .005 .025 .09 .00 .08 .012 IUD .00 .002 .023 .002 .005 .01 .01 .001 .006 Sterilization .001 .007 .041 .041 .027 .10 .14 .002 .002 Unmet need for contraceptionb,8 .22 .28 .29 .26 .35 .38 .13 .25 .31 Maternal mortality6 Live birthc 856 693 510 546d 343 634 138 371 315 Unsafe abortiond,e 80 80 100 100 100 40 40 80 80 Pregnancy outcomes (per 100 women)13 Live birth .77 .77 .76 .76 .76 .66 .66 .78 .78 Induced abortion .13 .13 .14 .14 .14 .24 .24 .12 .12 Spontaneous abortion .09 .09 .09 .09 .09 .09 .09 .09 .09 Ectopic pregnancy .01 .01 .01 .01 .01 .01 .01 .01 .01 Abbreviations: ART, antiretroviral therapy; ARVs, antiretrovirals; COC, combined oral contraceptive; DRC, Democratic Republic of the Congo; IUD, intrauterine device; POI, progestin-only injectable.
↵a The standard discount rate is routinely used in decision analysis to account for the fact that goods (dollars, health) are not as valuable in the future as they are in the present. Anywhere between 1.5% and 5% is considered a reasonable rate to discount health outcomes.37
↵b The number of women of reproductive age who are married or living with a partner who are fecund, are not using contraception, and report that they do not want any more children or wish to delay their next pregnancy, divided by the number of women of reproductive age who are married or living with a partner.
↵c 2015 WHO estimates of maternal mortality ratio (per 100,000 live births).
↵d Country-level data were not available and so regional estimates were used.
↵e 2008 WHO unsafe abortion rates (per 1,000 women ages 15–44 years).
- TABLE 2.
Comparison of Baseline Scenario of Current POI Use With the Scenario of Eliminating POIs From the Market and All POI Users Switching to No Method (per 100,000 Women)
Baseline Remove POIs Difference CENTRAL AFRICA Chad Change in life-years −9000 life-years lost New HIV cases (total) 171 155 −16 HIV cases New maternal HIV cases 161 134 −27 HIV cases New neonatal HIV cases 10 21 +11 HIV cases Maternal deaths 363 755 +391 maternal deaths Democratic Republic of the Congo Change in life-years −6600 life-years lost New HIV cases (total) 422 409 −13 HIV cases New maternal HIV cases 390 342 −48 HIV cases New neonatal HIV cases 32 67 +35 HIV cases Maternal deaths 190 500 +310 maternal deaths EASTERN AFRICA Kenya Change in life-years −6600 life-years lost New HIV cases (total) 423 409 −14 HIV cases New maternal HIV cases 398 349 −49 HIV cases New neonatal HIV cases 25 60 +35 HIV cases Maternal deaths 190 551 +341 maternal deaths Tanzania Change in life-years −7000 life-years lost New HIV cases (total) 267 259 −8 HIV cases New maternal HIV cases 248 217 −31 HIV cases New neonatal HIV cases 19 42 +23 HIV cases Maternal deaths 201 406 +210 maternal deaths Uganda Change in life-years −5000 life-years lost New HIV cases (total) 622 592 −30 HIV cases New maternal HIV cases 581 509 −72 HIV cases New neonatal HIV cases 41 83 + 42 HIV cases Maternal deaths 196 406 +210 maternal deaths SOUTHERN AFRICA Malawi Change in life-years −7500 life-years lost New HIV cases (total) 489 473 −16 HIV cases New maternal HIV cases 456 400 −56 HIV cases New neonatal HIV cases 33 73 +40 HIV cases Maternal deaths 252 565 +313 maternal deaths South Africa Change in life-years −1000 life-years lost New HIV cases (total) 1774 1771 −3 HIV cases New maternal HIV cases 1624 1507 −117 HIV cases New neonatal HIV cases 150 264 +114 HIV cases Maternal deaths 186 332 +146 maternal deaths WESTERN AFRICA Burkina Faso Change in life-year −4700 life-years lost New HIV cases (total) 47 46 −1 HIV case New maternal HIV cases 43 38 −5 HIV cases New neonatal HIV cases 4 8 + 4 HIV cases Maternal deaths 172 349 +177 maternal deaths Senegal Change in life-years −4500 life-years lost New HIV cases (total) 13 12 −1 HIV case New maternal HIV cases 12 10 −2 HIV cases New neonatal HIV cases 1 2 +1 HIV case Maternal deaths 147 304 +157 maternal deaths Abbreviation: POI, progestin-only injectable.
- TABLE 3.
Sensitivity Analysis Results: At What Threshold Valuea Would Removal of POIs Result in an Increase in Life-Years?
Variable Central Africa Eastern Africa Southern Africa Western Africa Chad DRC Kenya Tanzania Uganda Malawi South Africa Burkina Faso Senegal POI contraceptive failure rate 82.8% 78.7% 79.3% 81.4% 81.1% 81.0% 14.4% 84.2% 84.7% % of women switching to an equally effective methodb 96.9% 92.8% 93.5% 96.1% 95.4% 94.9% 15.2% 99.6% 100.0% Maternal mortality ratio –c –c –c –c –c –c −23% –c –c Abbreviation: DRC, Democratic Republic of the Congo.
↵a A threshold value indicates the value a variable would need to reach or exceed for removal of POIs to result in increased life-years. For example, in South Africa the maternal mortality ratio would need to decrease by 23% for the removal of POIs to be associated with increased life-years, assuming all other variables remain the same.
↵b Intrauterine device or implant.
↵c No threshold value exists; across all values of the maternal mortality ratio, removal of POIs results in loss of life-years.
In this issue
