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Volume 23, Number 1—January 2017
Research

Cost-effectiveness of Increasing Access to Contraception during the Zika Virus Outbreak, Puerto Rico, 2016

Rui LiComments to Author , Katharine B. Simmons, Jeanne Bertolli, Brenda Rivera-Garcia, Shanna Cox, Lisa Romero, Lisa M. Koonin, Miguel Valencia-Prado, Nabal Bracero, Denise J. Jamieson, Wanda Barfield, Cynthia A. Moore, Cara T. Mai, Lauren C. Korhonen, Meghan T. Frey, Janice Perez-Padilla, Ricardo Torres-Muñoz, and Scott D. Grosse
Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (R. Li, K.B. Simmons, J. Bertolli, S. Cox, L. Romero, L.M. Koonin, D.J. Jamieson, W. Barfield, C.A. Moore, C.T. Mai, L.C. Korhonen, M.T. Frey, J. Perez-Padilla, S.D. Grosse); Puerto Rico Department of Health, San Juan, Puerto Rico (B. Rivera-Garcia, M. Valenica-Prado, R. Torres-Muñoz); University of Puerto Rico and Puerto Rico Section of the American College of Obstetricians and Gynecologists, San Juan (N. Bracero)

Main Article

Table 3

Sensitivity analyses indicating the number of ZAM cases prevented and Zika virus–associated costs avoided in proposed intervention to increase access to contraception to women during Zika virus outbreak, Puerto Rico, 2016*

Parameter No. ZAM cases prevented Incremental intervention cost, millions Zika virus–associated cost avoided, millions Total incremental cost,† millions Cost per HLY gained Additional cost avoided from UP, millions
Main scenario
 25
 $33.5
 $65.2
 –$31.7
 CS
 $40.4
% Women receiving contraceptive services from healthcare provider; main scenario, 50% of no method users, 60% of less-effective method users, and 100% of moderately effective method users
30% of no method users‡ 22 $32.4 $55.8 –$23.5 CS $34.6
70% of no method users 29 $34.6 $74.5 –$39.9 CS $46.1
30% of less-effective method users 19 $26.0 $50.0 –$24.0 CS $31.0
80% of less-effective method users
29
 $38.5
 $75.2
 –$36.8
 CS
 $46.6
% Women receiving contraceptive services as in NSFG 2011–2013§ 16 $25.2 $40.6 –$15.4 CS $25.1
% Women willing to change to more effective method;¶ main scenario value: 50%
10% 6 $13.0 $15.8 –$2.8 CS $9.7
30% 16 $23.2 $40.5 –$17.3 CS $25.0
80% 39 $48.8 $102.2 –$53.3 CS $63.3
% Women receiving contraceptive services from healthcare provider as in NSFG 2011–2013 with 30% of them willing to change to a new method
 10
 $18.2
 $25.7
 –$7.6
 CS
 $15.9
Use of highly effective methods among switchers; main value 50%
67% 27 $38.4 $69.9 –$31.5 CS $43.3
33%
 23
 $28.5
 $60.4
 –$31.8
 CS
 $37.4
Contraception switching pattern reported in Colorado Family Planning Initiative#
 7
 $21.8
 $17.0
 $4.8
 $24,608
 $10.5
Dual-method use; 30% of moderately effective method users in main scenario
20% of moderately effective users 24 33.1 61.3 –$28.2 CS $38.0
50% of moderately effective users
 28
 34.1
 −72.9
 –$38.7
 CS
 $45.1
Contraception use distribution at baseline
As reported in 2002 BRFSS survey** 30 33.6 −78.4 –$44.8 CS $48.6
As in Title X clinics in 2014††
 14
 $30.1
 $36.7
 –$6.6
 CS
 $22.7
Rate of ZAM among all live-born infants; main scenario value 58/10,000
32/10,000 14 $33.5 $37.5 –$4.0 CS $40.4
86/10,000
 38
 $33.5
 $96.3
 –$62.8
 CS
 $40.3
Lifetime costs for microcephaly; main scenario value $3.8 million
$1.9 million 25 $33.5 $33.5 0 CN‡‡ $40.4
$2.2 million 25 $33.5 $39.5 –$6.1 CS $40.4
$5.5 million
 25
 $33.5
 $93.5
 –$60.0
 CS
 $40.4
Termination of pregnancy with ZAM
20% 25 $33.5 $72.8 –$39.3 CS $40.4
50%
 25
 $33.5
 $44.1
 –$10.6
 CS
 $40.3
Cost of the program other than providing the contraception at no cost to patients; main scenario value $39/person
$0/person 25 $27.1 $65.2 –$38.0 CS $40.4
$100/person
 25
 $43.4
 $65.2
 –$21.8
 CS
 $40.4
Annualized LARC device cost 25 $17.5 $65.2 –$47.7 CS $40.4
Puerto Rico costs§§
 25
 $30.8
 $32.5
 –$1.7
 CS
 $14.4
Discount rate
0% 25 $33.5 $105.4 –$72.0 CS $40.4
5% 25 $33.5 $52.9 –$19.4 CS $40.4

*BRFSS, Behavioral Risk Factor Surveillance System; CN, cost-neutral; CS, cost-saving; HLY, healthy life years; LARC, long-acting reversible contraceptive; NSFG, National Survey of Family Growth; UP, unwanted pregnancy; ZAM, Zika virus–associated microcephaly.
†Total incremental cost is the additional cost of contraception minus Zika virus–associated cost avoided.
‡30% of no contraception users, 60% of less-effective contraceptive method users, 100% of moderately effective contraceptive method users seeking contraceptive services from healthcare provider during the Zika virus outbreak.
§Based on NSFG 2011–2013, among women of reproductive age who are sexually active, did not intend to become pregnant, and were not using permanent contraceptive methods, 21% of no contraception users, 33% of less-effective contraceptive method users, 97% of moderately effective contraceptive method users, and 94% of dual-method users had at least 1 contraceptive service visit in the last 12 months (in total 50%).
¶Based on Title X Family Planning annual report for 2007–2015 in Colorado, 30% of clients who visited Title X clinics switched to a new method.
#Eighteen percentage points of users of moderately effective methods are assumed to switch to highly effective methods, of whom 21% were dual-method users.
**Contraception distribution in Puerto Rico in 2002 15.9% no method, 41.6% less-effective methods, 40.2% moderately effective methods, and 2.4% highly effective methods.
††In 2014, in Title X clinics in Puerto Rico, 20% of women at risk for unintended pregnancy used less-effective methods, 77% used moderately effective methods, and 2% used highly effective methods.
‡‡Intervention cost equals to the medical savings from ZAM cases prevented.
§§Conversion factor of 0.36 applied to pregnancy and ZAM medical costs based on the ratio of per capita medical expenditure in Puerto Rico and in the United States in 2012 as in Portela et al. 2015 (32); conversion factor of 0.72 applied to costs of supportive care for live-born infants with ZAM, based on the ratio of annual salary for assistant nurses in Puerto Rico and in the United States (33).

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